HomeMy WebLinkAboutContract 47293 City SECRETAW
CONTPACT No. w
STATE OF TEXAS §
COUNTY OF TARRANT §
This contract ("Contract") is made and entered into by and between the City of Fort Worth
(hereafter "City") and Tarrant County Samartian House, Inc. (hereafter "Agency"), a Texas non-
profit corporation. City and Agency may be referred to individually as a "Party" and jointly as
"the Parties".
The Parties state as follows:
WHEREAS, City receives grant monies from the United States Department of Housing and
Urban Development through the Housing Opportunities for Persons with AIDS Program
("HOPWA") Program, Program No. TX-H-15-F002, Catalog of Federal Domestic Assistance No.
14.241;
WHEREAS, the HOPWA program is intended to address the needs of eligible persons
associated with the challenge of living with HIV/AIDS and their families;
WHEREAS, Agency submitted a proposal to use HOPWA funds for an eligible program
under the HOPWA Regulations whereby Agency will provide services to low and moderate
income City citizens;
WHEREAS, City citizens, the Community Development Council, and the City Council
have determined that HOPWA programs are needed by the City's citizens;
NOW, THEREFORE, the Parties understand and agree as follows:
1. INCORPORATION OF RECITALS
City and Agency hereby agree that the recitals set forth above are true and correct and form
the basis upon which the Parties have entered into this Contract.
2. DEFINITIONS
In addition to terms defined in the body of this Contract, the terms set forth below shall
have the definitions ascribed to them as follows:
Area Median Income or AMI means the median family income for the Fort Worth-Arlington
metropolitan statistical area as established annually by HUD. The 2015 income limits are attached
hereto as EXHIBIT "A-1"—2015 HUD Income Limits.
Business Diversity Enterprise Ordinance or BDE means the City's Business Diver,sr y
Ordinance, Ordinance No. 20020-12-2011. "%"I
Complete Documentation means the following documentation as applicable: .
Hopwa Psa corrTRacT 2015-20I6 01"FICIAL RECORD Pa�ge�"i
Tarrant County Samaritan House, Inc. Rev.10.02.,�,QI F( %h)
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• Attachments I, II, and III, with supporting documentation including:
• Proof of expense: copies of timesheets, invoices, leases, service contracts or
other documentation showing that payment is due by Agency.
• Proof of payment: cancelled checks, bank statements, or wire transfers
necessary to demonstrate that amounts due by Agency were actually paid by
Agency.
• Proof of client eligibility: Source Documentation sufficient to show that
clients participating in the Program are HOPWA Eligible Clients as
described in Section 6.
• Complete Documentation shall meet the standards described in the attached
EXHIBIT "F"- Standards for Complete Documentation.
• Any other document or record reasonably necessary to verify costs spent and client
eligibility for the Program.
DBE means disadvantaged business enterprise in accordance with 49 CFR Part 26.
Director means the Director of the City's Neighborhood Services Department.
Effective Date means October 1, 2015.
HOPWA means Housing Opportunities for Persons with AIDS.
HOPWA Eligible Client means a client whose annual income adjusted for family size does not
exceed 80% of AMI using the most current HUD Income Guidelines and Technical Guidance for
Determining Income and Allowances verified by either Source Documentation or the form in in
EXHIBIT "E" - Form of Income Self-Certification. The client must also have a documented
diagnosis of HIV/AIDS.
HOPWA Funds means the HOPWA grant funds supplied by City to Agency under the terms of
this Contract.
HOPWA Regulations means regulations found at 24 CFR Part 574 et seq.
HUD means the United States Department of Housing and Urban Development.
IDIS means Integrated Disbursement Information System, HUD's project tracking system.
Neighborhood Services Department means the City's Neighborhood Services Department.
OMB means the Office of Management and Budget.
Program means the services described in EXHIBIT "A"—Program Summary.
Reimbursement Request means all reports and other documentation described in Section 9.
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Source Documentation means documentation of full household income of any type described
under the definition of annual income in 24 CFR Part 5.609, including but not limited to copies of
paychecks, Social Security and disability verification letters, interest or rental income statements,
retirement income statements, child support and alimony verification, unemployment benefit
letters, and the like.
Unduplicated Clients means a count of HOPWA Eligible Clients served at least once in the
Contract Term. HOPWA Eligible Clients served more than once in the Contract Term will only be
counted the first time they are served when determining the total count of Unduplicated Clients.
3. TERM.
The term of this Contract begins on October 1, 2015 and terminates on September 30,
2016 unless earlier terminated as provided in this Contract.
4. DUTIES AND RESPONSIBILITIES OF CITY.
4.1 Provide HOPWA Funds.
City shall provide up to $420,063.00 of HOPWA Funds under the terms and conditions of
this Contract.
4.2 Monitor.
City will monitor the activities and performance of Agency and any of its contractors,
subcontractors or vendors as necessary, but no less than annually. Monitoring by City will
include determining whether Agency is meeting the requirements of the HOPWA Regulations
during the term of this Contract.
5. DUTIES AND RESPONSIBILITIES OF AGENCY.
5.1 Required Services.
Agency shall perform the services described in EXHIBIT "A" — Program Summary in
accordance with the terms and conditions of this Contract.
5.2 Use of HOPWA Funds.
5.2.1. Compliance with HOPWA Regulations and Contract.
Agency shall be reimbursed for eligible Program costs with HOPWA Funds only if City
determines in its sole discretion that:
5.2.1.1 Costs are eligible expenditures in accordance with HOPWA
Regulations.
5.2.1.2 Costs are in compliance with this Contract and are reasonable and consistent
with industry norms.
5.2.1.3 Complete Documentation, as applicable, is submitted to City by Agency.
5.2.2 Budget
5.2.2.1 The HOPWA Funds will be paid on a reimbursement basis in
accordance with EXHIBIT "B" - Budget.
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5.2.2.2 During the term of this Contract, Agency may submit written requests to
increase or decrease line-item amounts in the Budget, including an
explanation of why such increases or decreases are necessary. All such
requests must be approved by the Director in writing, with such approval
being in the Director's sole discretion. If Director approves the
Agency's proposed Budget amendment (as approved, the "Amended
Budget"), then the Amended Budget will take effect on the first day of
the month following the month in which it was approved by Director,
unless otherwise specified in the amendment. All requests for Budget
amendments must be submitted by June 1,2016.
5.2.3 Change in Program Budget.
5.2.3.1 Agency will notify City promptly of any additional funds it receives for
operation of the Program, and City reserves the right to amend this
Contract in such instances to ensure compliance with HUD regulations
governing cost allocation.
5.2.3.2 Agency agrees to utilize the HOPWA Funds to supplement rather than
supplant funds otherwise available for the Program.
5.2.4 Payment of HOPWA Funds to Agency.
HOPWA Funds will be disbursed to Agency upon City's approval of Reimbursement
Requests including submission of Complete Documentation to City in compliance with Section 9.
If Agency expends all funds budgeted for the Program prior to September 30, 2016, City may
hold back a small amount of the HOPWA Funds until the end of the term. During this interim
period, Agency must continue to submit Reimbursement Requests with an invoiced amount of$0.
It is expressly agreed by the Parties that any HOPWA Funds not spent or not approved for
reimbursement to Agency shall remain with City.
5.3 Program Performance Milestones.
5.3.1 Agency represents that the Program will achieve the following milestones in
accordance with EXHIBIT "A"—Program Summary and the table below:
Unduplicated Clients as
specified in EXHIBIT
"A"=Program
Month Expenditures Summa
3 25% 25%
6 50% 50%
8 75% 75%
12 100% 100%
5.3.2 Failure of Agency to meet these milestones or a material deviation from them as
outlined in this Section 5.3 is a breach of this Contract. For the purpose of this Section, "material
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deviation" shall mean more than 10% lower than the specified goal. In the event of such breach,
City reserves the right in its sole option to delay or withhold payment of Reimbursement Requests,
to lower Agency's allocation of HOPWA Funds, or to terminate this Contract.
5.3.3 Failure to meet at least 80% of its performance milestones or serve 128
Unduplicated Clients will automatically disqualify Agency for consideration under the City's
Request for Proposals for the 2016-2017 Program Year for federal grant funds.
5.3.4 Amendments to performance milestones must be approved by the Director in
writing, with such approval being in the Director's sole discretion. If Director approves the
Agency's proposed amended performance milestones (as approved, the "Amended Performance
Milestones"), then the Amended Performance Milestones will take effect on the first day of the
month following the month in which it was approved by Director, unless otherwise specified in the
amendment. All requests for amendments to performance milestones must be submitted by June
1, 2016. Notwithstanding the above, any amendments to this Contract shall not reduce the number
of Unduplicated Clients stated in Section 5.3.3 and in EXHIBIT "A"—Program Summary.
5.4 Identify Program Expenses Paid with HOPWA Funds.
Agency will keep accounts and records in such a manner that City may readily identify and
account for Program expenses reimbursed with HOPWA Funds. These records shall be made
available to City for audit purposes and shall be retained as required hereunder.
5.5 Program Subcontracts.
Agency shall not enter into a subcontract with another agency, contractor, or vendor to
provide a service to clients for any part of the Program that will be paid with HOPWA Funds
without City's written consent.
6. CLIENT ELIGIBILITY VERIFICATION.
6.1 Client Eligibility.
Agency will document the eligibility of all prospective clients. Agency may redact the
client's personal information and substitute a client number. Agency will document client
eligibility as follows:
6.1.1 Income.
Agency must verify all new clients' income eligibility with either Source Documentation or
the form attached as EXHIBIT "E" - Form of Income Self Certification. Agency must use the
annual income definition used by 24 CFR Part 5.609 to establish client income eligibility and must
use the most current HUD Income Guidelines.
6.1.2 Diagnosis.
Agency must submit a signed, dated statement that the client's file contains documentation
of the client's diagnosis of HIV/AIDS. The HIV/AIDS diagnosis must be made by a licensed
health care provider; a client's self-certification of diagnosis is not sufficient. Agency should not
submit the actual diagnosis to City.
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6.1.3 Emergency Need.
For clients receiving short term rental, mortgage or utility assistance, Agency must also
verify and document that the client has an emergency need, such as sudden loss of income,
eviction, utility shutoff, or extraordinary and unexpected healthcare costs. Agency must submit its
policy regarding documenting emergency need to City by October 1,2015.
6.2 Submission of Complete Documentation.
Agency must submit copies of documentation of client eligibility described in Section 6.1
with Attachment III in each month's Reimbursement Request for all Unduplicated Clients.
6.3 Maintain Documentation.
Agency must maintain copies of all documentation required by this Section 6 for 5 years
following the expiration of the Contract term. This Section shall survive the earlier terminations or
expirations of this Contract.
7. ADDITIONAL HOPWA REQUIREMENTS.
Agency agrees to comply with all requirements of the HOPWA Program as stated in the
HOPWA Regulations, including but not limited to the following:
7.1 Environmental Review.
HOPWA Funds will not be paid, and costs cannot be incurred until City has conducted an
environmental review and completed an Environmental Review Record as required by 24 CFR
Part 58. The environmental review may result in a decision to proceed with, modify, or cancel the
funding for the Program. Further, Agency will not undertake or commit any funds to physical or
choice limiting actions as described in any applicable federal regulations. Any violation of this
provision will (i) cause this Contract to terminate immediately; and (ii) require Agency to repay
City the HOPWA Funds it has already received and forfeit any future payments of HOPWA
Funds.
7.2 Contract Not Constituting Commitment of Funds.
Notwithstanding any provision of this Contract, the Parties agree and acknowledge that this
Contract does not constitute a commitment of funds, and that such commitment of funds or
approval may occur only upon (i) satisfactory completion of environmental review and receipt by
City of an authorization to use grant funds from HUD under 24 CFR Part 58, (ii) approval of
City's 2015-2016 Action Plan, and (iii) receipt by City of grant agreement from HUD.
7.3 Monitoring.
7.3.1 Agency understands and agrees that it will be subject to monitoring by City for
compliance with terms and provisions of this Contract and the HOPWA Regulations for the term
of this Contract. Agency is subject to such monitoring during the term of this Contract and for 5
years after the Contract term ends. Agency will provide reports and access to Program files as
requested by City during this 5 year period. For purposes of this Contract, this 5 year period for
monitoring is deemed to begin on October 1, 2016 and end on September 30, 2021 regardless of
whether or not this Contract is earlier terminated.
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7.3.2 Representatives of City, HUD, HUD Office of Inspector General, and the United
States Comptroller General shall have access during regular business hours, upon 48 hours prior
notice, to Agency's offices and records pertaining to the use of the HOPWA Funds, and to
Agency's officers, directors, agents, employees, contractors, subcontractors and vendors for the
purpose of such monitoring.
7.3.3 In addition to other provisions of this Contract regarding frequency of monitoring,
City reserves the right to perform desk reviews or on-site monitoring of Agency's compliance with
the terms and conditions of this Contract. City shall provide Agency with a written report of the
monitor's findings after each monitoring visit. If the monitoring report notes deficiencies in
Agency's performance, the report shall include requirements for the timely correction of said
deficiencies by Agency. Failure by Agency to take the action specified in the monitoring report
may be cause for suspension or termination of this Contract as provided herein.
7.3.4 Subsections 7.3.1 through 7.3.3 shall be applicable for the Contract term and for 5
years thereafter and shall survive the earlier termination or expiration of this Contract.
7.3.5 Agency shall provide City annually the results of any state or federal monitoring.
Such results shall be submitted within 60 days of receipt of such state or federal monitoring report,
or with the January Reimbursement Request, whichever is earlier.
7.4 Agency Procurement Standards.
Agency shall comply with all applicable federal, state and local laws, regulations, and
ordinances for making procurements under this Contract. In addition to the conflict of interest
provision in Section 14.13.3, Agency shall establish written procurement procedures to ensure that
materials and services are obtained in a cost effective manner and that provides for full and open
competition. When procuring materials and services for this Contract, Agency shall comply at a
minimum with the procurement standards in 2 CFR Part 200.317 through 2 CFR Part 200.326.
7.4.1 Contracts in excess of $10,000.00 made by Agency using CDBG Funds must
address termination for cause and convenience including the manner by which such termination
shall be effected and the basis for settlement of the terminated contract, if any, as required by
Appendix II (B), 2 CFR Part 200.
7.4.2 Agency shall not make any contract with parties listed on the governmentwide
System for Award Management, www.sam.gov ("SAM"). Agency must confirm by search of
SAM that all contractors paid with CDBG Funds are not listed by SAM as being debarred, both
prior to hiring and prior to submitting a Reimbursement Request which includes invoices from any
such contractor. Failure to submit such proofs of search shall be an event of default.
7.5 Cost Principles/Cost Reasonableness.
Agency shall administer its use of HOPWA Funds in compliance with 2 CFR Part 200, as
applicable. The eligibility of costs incurred for performance rendered shall be determined in
accordance 2 CFR Part 200.400 through 2 CFR Part 200.475.
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7.6 Accounting Standards.
Agency agrees to comply with 2 CFR Part 200, as applicable. Agency also agrees to
adhere to the accounting principles and procedures required therein, utilize adequate internal
controls, and maintain necessary supporting and back-up documentation for all costs incurred in
accordance with 2 CFR Part 200.302 and Part 200.303.
7.7 Uniform Administrative Requirements, Cost Principles, and Audit
Requirements.
Agency will comply with the Uniform Administrative Requirements, Cost Principles, and
Audit Requirements for Federal Awards in 2 CFR Part 200, as applicable, or any reasonably
equivalent procedures and requirements that City may require.
7.8 Terms Applicable to Contractors, Subcontractors and Vendors.
Agency understands and agrees that all terms of this Contract, whether regulatory or
otherwise, shall apply to any and all contractors, subcontractors and vendors of Agency which are
in any way paid with HOPWA Funds or who perform any work in connection with the Program.
Agency shall cause all applicable provisions of this Contract to be included in and made a part of
any contract or subcontract executed in the performance of its obligations hereunder including its
obligations regarding the HOPWA Regulations. Agency shall monitor the services and work,
performed by its contractors, subcontractors and vendors on a regular basis for compliance with
the HOPWA Regulations and Contract provisions. Agency must cure all violations of the
HOPWA Regulations committed by its contractors, subcontractors or vendors. City maintains the
right to insist on Agency's full compliance with the terms of this Contract and the HOPWA
Regulations and Agency is responsible for such compliance regardless of whether actions taken to
fulfill the requirements of this Contract are taken by Agency or by Agency's contractors,
subcontractors or vendors. Agency acknowledges that the provisions of this Section shall survive
the earlier termination or expiration of this Contract and shall be applicable for 5 years after the
Contract Term ends.
7.9 Copyriaht and Patent Rights.
No reports, maps, or other documents produced in whole or in part under this Contract shall
be the subject of an application for copyright by or on behalf of Agency. HUD and City shall
possess all rights to invention or discovery, as well as rights in data, which may arise as a result of
Agency's performance under this Contract.
7.10 Conflict of Interest Disclosure.
In accordance with the requirements of Section 14.13.2.1 and 14.13.4, Agency shall
establish conflict of interest policies for federal awards. Agency shall disclose to City in writing
any potential conflict of interest.
7.11 Compliance with FFATA and Whistleblower Protections.
Agency shall comply with the requirements of 2 CFR 300(b), including provisions of the
Federal Funding Accountability and Transparency Act ("FFATA") governing requirements on
executive compensation and provisions governing whistleblower protections contained in 10
U.S.C. 2409, 41 U.S.C. 4712, 10 U.S.C. 2324, 41 U.S.C. 4304 and 41 U.S.C. 4310.
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7.11.1 Agency shall provide City with its DUNS number.
7.12 Internal Controls.
In compliance with the requirements of 2 CFR Part 200.303, Agency shall:
7.12.1 Establish and maintain effective internal control over the HOPWA Funds that
provides reasonable assurance that Agency is managing the HOPWA Funds in compliance with
federal statutes, regulations, and the terms and conditions of this Contract. These internal controls
shall be in compliance with guidance in "Standards for Internal Control in the Federal
Government" issued by the Comptroller General of the United States or the "Internal Control
Integrated Framework" issued by the Committee of Sponsoring Organizations of the Treadway
Commission ("COSO");
7.12.2 Comply with federal statutes, regulations, and the terms and conditions of this
Contract;
7.12.3 Evaluate and monitor Agency's compliance with statutes, regulations and the terms
and conditions of this Contract;
7.12.4 Take prompt action when instances of noncompliance are identified including
noncompliance identified in audit findings; and
7.12.5 Take reasonable measures to safeguard protected personally identifiable
information and other information that HUD or City designates as sensitive or Agency considers
sensitive consistent with applicable federal, state, local and tribal laws regarding privacy and
obligations of confidentiality.
7.13 Required Certification of Completion of Training.
At least 1 Agency employee must complete the HUD required "Getting to Work Training
Curriculum" by April 15, 2016 and submit the required certifications to City with the April 2016
Reimbursement Request as more particularly described on EXHIBIT "A-2" —Requirements for
Completion of"Getting to Work Training Curriculum".
8. RECORD KEEPING; REPORTING AND DOCUMENTATION REQUIREMENTS;
AUDIT.
8.1 Record Keeping.
Agency shall maintain a record-keeping system as part of its performance of this Contract
and shall promptly provide City with copies of any document City deems necessary for the
effective fulfillment of City's monitoring and evaluation responsibilities. Specifically, Agency
will keep or cause to be kept an accurate record of all actions taken and all funds spent, with
supporting and back-up documentation. Agency will maintain all records and documentation
related to this Contract for 5 years after the Contract term ends. If any claim, litigation, or audit is
initiated before the expiration of the 5 year period, the relevant records and documentation must be
retained until all such claims, litigation or audits have been resolved. For purposes of this
Contract, this 5 year period for record retention is deemed to begin on October 1,2016 and end on
September 30,2021 regardless of whether or not this Contract is earlier terminated.
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8.2 Access to Records.
Representatives of City, HUD and any duly authorized officials of the federal government
will have full access to, and the right to examine, audit, copy, excerpt and/or transcribe any of
Agency's records pertaining to all matters covered by this Contract for 5 years after the Contract
term ends. Such access shall be during regular business hours and upon at least 48 hours prior
notice. For purposes of this Contract, this 5 year period for access to records is deemed to begin
on October 1, 2016 and end on September 30, 2021 regardless of whether or not this Contract is
earlier terminated.
8.3 Reports.
Agency will submit to City all reports and documentation described in this Contract in such
form as City may prescribe. Agency may also be required to submit a final performance and/or
final financial report if required by City at the termination of this Contract in such form and within
such times as City may prescribe. Failure to submit to City any report or documentation described
in this Contract shall be an event of default of this Contract and City may exercise all of its
remedies for default under this Contract.
8.3.1 Additional Information.
Agency shall provide City with additional information as may be required by state or
federal agencies to substantiate Program activities and/or expenditure eligibility.
8.4 Chance in Reporting Requirements and Forms
City retains the right to change reporting requirements and forms at its discretion. City will
notify Agency in writing at least 15 days prior to the effective date of such change, and the Parties
shall execute an amendment to the Contract reflecting such change if necessary.
8.5 Audit
8.5.1 Entities that Expend $750,000 or more in Federal Funds Per Year
All non-federal entities that expend $750,000 or more in federal funds within 1 year,
regardless of the source of the federal award, must submit to City an annual audit prepared in
accordance with specific reference to 2 CFR Part 200.501 through Part 200.521. The audit shall
cover the Agency's fiscal years during which this Contract is in force. The audit must be prepared
by an independent certified public accountant, be completed within 6 months following the end of
the period being audited and be submitted to City within 30 days of its completion. Agency's
audit certification is attached hereto as EXHIBIT "C" — "Audit Certification Form" and "Audit
Requirements". The Audit Certification Form must be submitted to City prior to or with the
first Reimbursement Request. Entities that expend less than $750,000 a year in federal funds are
exempt from federal audit requirements for that year, but records must be available for review or
audit by appropriate officials of the federal agency, City, and General Accounting Office.
8.5.2 City Reserves the RiL-ht to Audit.
City reserves the right to perform an audit of Agency's Program operations and finances at
any time during the term of this Contract and for 5 years after the Contract Term ends if City
determines that such audit is necessary for City's compliance with the HOPWA Regulations or
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other City policies. Agency agrees to allow access to all pertinent materials as described herein for
such audit. For purposes of this Contract, this 5 year period for City audit is deemed to begin on
October 1, 2016 and end on September 30, 2021 regardless of whether or not this Contract is
earlier terminated. If such audit reveals a questioned practice or expenditure, such questions must
be resolved within 15 business days after notice to Agency of such questioned practice or
expenditure. If questions are not resolved within this period, City reserves the right to withhold
further funding under this Contract and/or any other contracts with Agency. IF AS A RESULT
OF ANY AUDIT IT IS DETERMINED THAT AGENCY HAS FALSIFIED ANY
DOCUMENTATION OR MISUSED, MISAPPLIED OR MISAPPROPRIATED HOPWA
FUNDS OR SPENT HOPWA FUNDS ON ANY INELIGIBLE ACTIVITIES, AGENCY
AGREES TO REIMBURSE CITY THE AMOUNT OF SUCH MONIES PLUS THE
AMOUNT OF ANY SANCTIONS, PENALTY OR OTHER CHARGE LEVIED AGAINST
CITY BY HUD BECAUSE OF SUCH ACTIONS.
9. REIMBURSEMENT REQUIREMENTS
9.1 Deadline for Submitting Reimbursement Requests.
9.1.1 Reimbursement Requests shall be submitted monthly to the City and must be
received by the City on or before the 15th day of the month following the month expenses were
paid by Agency. For example, the Reimbursement Request for June expenses must be received by
July 15. In the event the 15th falls on a weekend or City holiday, Reimbursement Requests shall
be due the next day that the City is open for business. Failure to submit a Reimbursement Request
in a timely fashion will result in City taking the actions outlined in Section 10.1.
NOTWITHSTANDING ANYTHING ABOVE, THE REIMBURSEMENT REQUEST FOR
EXPENSES INCURRED FOR SEPTEMBER 2016 MUST BE RECEIVED BY OCTOBER
1, 2016. FAILURE TO SUBMIT A FINAL REIMBURSEMENT REQUEST WITH
COMPLETE DOCUMENTATION BY OCTOBER 15, 2016 WILL RESULT IN
FORFEITURE OF PAYMENT OF THE SEPTEMBER REIMBURSEMENT REQUEST.
9.1.2 City will notify Agency by e-mail within 20 calendar days if a Reimbursement
Request is lacking Complete Documentation or corrections are needed. Agency will have 10
business days from the date of the e-mail notice to submit any requested information or missing
documentation. Agency will be penalized in the Request for Proposal for the 2016-2017 Program
Year for any notifications received under this Section. If Agency fails to submit all the required
information or missing documentation within 30 calendar days from the first e-mail, Agency shall
forfeit any payments otherwise due that month and failure to submit any requested information
will be considered an event of default as outlined in Section 10.1.2.
9.2 Submission of Reimbursement Requests.
Agency shall provide City with Complete Documentation and the following reports as
shown in EXHIBIT "D"—Reimbursement Forms with each Reimbursement Request:
9.2.1 Attachment I—Invoice
This report shall contain the amount requested for reimbursement each month, the
cumulative reimbursement requested to date (inclusive of that month's request), and must be
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signed by an authorized signatory of Agency. By signing Attachment I, Agency is certifying that
the costs are valid, eligible, consistent with the terms and conditions of this Contract, and the data
contained in the report is true and correct. This report must be submitted even if Agency is
requesting $0 for a particular month.
9.2.1.1 Agency must submit a separate invoice for each activity type, i.e.
Administration, Facility Based Operating Costs, Supportive Services,
Short-term Rent, Mortgage and Utility Assistance ("STRMU"), and
Tenant Based Rental Assistance ("TBRA").
9.2.2 Attachment II—Expenditure Worksheet
This report shall itemize each expense requested for reimbursement by Agency and shall
include the Account corresponding the expense to a Budget line item. In order for this report to be
complete the following must be submitted:
9.2.2.1 For payroll expenses, timesheets signed by employees and approved by
supervisor for all payroll expenses listed. Timesheets must distinguish
between HOPWA-funded time and non-HOPWA funded time and
reflect actual time spent on HOPWA-funded activities. Agency may not
submit payroll expenses dated 60 calendar days prior to the date of the
Reimbursement Request.
9.2.2.2 For non-payroll expenses, invoices for each expense listed with an
explanation as to how the invoiced expense pertains to the Program.
Agency may not submit invoices dated 60 calendar days prior to the date
of the Reimbursement Request.
9.2.2.3 Proof that each expense was paid by Agency, which proof can be
satisfied by canceled checks, wire transfer documentation, paid receipts
or other appropriate banking documentation.
9.2.3 Attachment III—Client Data Report.
This report shall list each Unduplicated Client served during the month along with his or
her demographic information. The Client Data Report must maintain a list of all clients served
during the Contract term. In order for this report to be complete, the following must be submitted:
9.2.3.1 Documentation of income verification for each Unduplicated Client the
first time the client is served by the Program, which will either be the
completed form of EXHIBIT "E"- Form of Income Self Certification
or Source Documentation.
9.2.4 Overview Report.
Agency shall submit the Overview Report, attached hereto as EXHIBIT "H" — Overview
Report, quarterly with the January, April, July and October Reimbursement Requests. A paper
copy must be submitted with the Reimbursement Request, and an electronic copy must also be
emailed to psa(afortworthtexas.jjov.
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9.2.5 Delivery of Reimbursement Request.
Reimbursement Requests can be mailed or delivered in person to Neighborhood Services
Department, 908 Monroe Street, Fort Worth, Texas 76102. In addition, Agencies can submit
Reimbursement Requests via email to psa(affortworthtexas.gov, but Agency must submit a signed
original of Attachment I by the deadline in Section 9.1.1.
9.3 Withholding Payment.
CITY SHALL HAVE NO OBLIGATION TO PAY ANY REIMBURSEMENT
REQUEST THAT IS NOT RECEIVED BY THE DUE DATE. Failure to timely submit
Reimbursement Requests and Complete Documentation along with any required reports
shall be an event of default.
10. DEFAULT AND TERMINATION.
10.1 Failure to Submit Reimbursement Request or Required Documentation.
10.1.1 If Agency fails to submit a Reimbursement Request in accordance with Section
9, Agency shall be in default of this Contract. City will notify Agency in writing of such default
and the Agency will have 10 business days from the date of the written notice to submit such
Reimbursement Request to cure the default. If Agency fails to cure the default within such time,
Agency shall forfeit any payments otherwise due that month.
10.1.2 If Agency fails to submit requested information or missing documentation as set
forth in Section 9.1.2, then Agency shall forfeit payment due that month and the failure to submit
shall be considered an event of default that shall not be cured.
10.1.3 NOTWITHSTANDING THE PROVISIONS OF SECTION 10.1.1 OR
10.1.2, IF AGENCY FAILS TO SUBMIT THE REIMBURSEMENT REQUEST DUE
OCTOBER 1, 2016, OR IF THE SUBMITTED REIMBURSEMENT REQUEST FOR
OOCTOBER 1, 2016 IS LATE,INCOMPLETE OR OTHERWISE NOT IN COMPLIANCE
WITH THIS CONTRACT OR THE HOPWA REGULATIONS AS DETERMINED BY
CITY IN ITS SOLE DISCRETION, THERE WILL BE NO CURE PERIOD AND ANY
REIMBURSEMENT WILL BE FORFEITED.
10.1.4 In the event of(i) an uncured default under Section 10.1.1 or an event of default
under 10.1.2 (ii) or more than 2 instances of default, cured or uncured, under these Sections, City
reserves the right at its sole option to terminate this Contract effective immediately upon written
notice of such intent with no penalty or liability to City.
10.1.5 Notwithstanding anything to the contrary herein, City will not be required to
pay any HOPWA Funds to Agency during the period that any Reimbursement Request, report or
documentation is past due or is not in compliance with this Contract or the HOPWA Regulations,
or during any period during which Agency is in default of this Contract.
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10.1.6 In the event of termination under this Section 10.1, all HOPWA Funds awarded
but unpaid to Agency pursuant to this Contract shall be immediately forfeited and Agency shall
have no further right to such funds.
10.2 Failure to Maintain Records or Submit Reports and Documentation.
If Agency fails to maintain all records and documentation as required in Section 8, or if the
maintained or submitted report or documentation is not in compliance with this Contract or the
HOPWA Regulations as determined by City in its sole discretion, City will notify Agency in
writing and Agency will have 30 calendar days from the date of the written request to obtain or
recreate the missing records and documentation or submit or resubmit any such report or
documentation to City. If Agency fails to maintain the required reports or documentation, or fails
to submit or resubmit any such report or documentation within such time, City shall have the right
to terminate this Contract effective immediately upon written notice of such intent with no penalty
or liability to City.
10.2.1 In the event of termination under this Section 10.2, all HOPWA Funds awarded
but unpaid to Agency pursuant to this Contract shall be immediately forfeited and Agency shall
have no further right to such funds, and any HOPWA Funds paid to Agency must be repaid to City
within 30 days of termination. If such HOPWA funds are not repaid to City within the 30 day
period, City shall exercise all legal remedies available under this Contract.
10.3 In General.
10.3.1 Subject to Section 10.2, and unless specifically provided otherwise in this
Contract, Agency shall be in default under this Contract if Agency breaches any term or condition
of this Contract. In the event that such a breach remains uncured after 30 calendar days following
written notice by City (or such other notice period as may be specified herein) or, if Agency has
diligently and continuously attempted to cure following receipt of such written notice but
reasonably requires more than 30 calendar days to cure, as determined by both Parties mutually
and in good faith, City shall have the right to elect in City's sole discretion to (i) extend Agency's
time to cure, (ii) terminate this Contract effective immediately upon written notice of such intent to
Agency, or (iii)pursue any other legal remedies available to City under this Contract.
10.3.2 City's remedies may include:
10.3.2.1 Direct Agency to prepare and follow a schedule of actions for
carrying out the affected activities, consisting of schedules,
timetables and milestones necessary to implement the affected
activities.
10.3.2.2 Direct Agency to establish and follow a management plan that
assigns responsibilities for carrying out the remedial activities.
10.3.2.3 Reprogram HOPWA Funds that have not yet been expended from
affected activities to other eligible activities or withhold HOPWA
Funds.
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10.3.2.4 Any other appropriate action including but not limited to any
remedial action legally available such as declaratory judgment,
specific performance, damages, temporary or permanent injunctions,
termination of this Contract or any other contracts with Agency, and
any other available remedies.
10.3.3 In the event of termination under this Section 10.3, all HOPWA Funds awarded
but unpaid to Agency pursuant to this Contract shall be immediately forfeited and Agency shall
have no further right to such funds, and any HOPWA Funds already paid to Agency must be
repaid to City within 30 days of the termination. Failure to repay such HOPWA Funds within the
30 day period will result in City exercising all legal remedies available under this Contract.
10.4 No Funds Disbursed while in Breach.
Agency understands and agrees that no HOPWA Funds will be paid to Agency until all
defaults are cured to City's satisfaction.
10.5 No Compensation After Date of Termination.
Agency shall not receive any compensation for work undertaken after the date of the
termination.
10.6 Rights of City Not Affected.
Termination shall not affect or terminate any of the existing rights of City against Agency,
or which may thereafter accrue because of Agency's default and this provision shall be in addition
to any and all other rights and remedies available to City under the law. Such termination does not
terminate any provisions of this Contract that have been expressly noted as surviving the term or
termination of the Contract. No delay or omission by City in exercising any right or remedy
available to it under this Contract shall impair any such right or remedy or constitute a waiver or
acquiescence in any Agency default.
10.7 Waiver of Breach Not Waiver of Subsequent Breach
The waiver of a default or breach of any term, covenant, or condition of this Contract shall
not operate as a waiver of any subsequent default or breach of the same or any other term,
covenant or condition hereof.
10.8 Civil Criminal and Administrative Penalties
Failure to perform all the Contract terms may result in civil, criminal or administrative
penalties, including, but not limited to those set out in this Contract.
10.9 Termination for Cause
10.9.1 City may terminate this Contract in the event of Agency's default, inability, or
failure to perform subject to notice, grace and cure periods. In the event City terminates this
Contract for cause, all HOPWA Funds awarded but unpaid to Agency pursuant to this Contract
shall be immediately rescinded and Agency shall have no further right to such funds and any
HOPWA Funds already paid to Agency must be repaid to City within 30 days of termination.
Failure to repay such HOPWA Funds within 30 days will result in City exercising all legal
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remedies available to City under this Contract. AGENCY ACKNOWLEDGES AND AGREES
THAT IF CITY TERMINATES THIS CONTRACT FOR CAUSE, AGENCY OR ANY
AFFILIATES OF AGENCY SHALL NOT BE CONSIDERED FOR ANY OTHER CITY
CONTRACT FOR HOPWA FUNDS FOR A MINIMUM OF 5 YEARS FROM THE DATE
OF TERMINATION.
10.9.2 Agency may terminate this Contract if City does not provide the HOPWA
Funds substantially in accordance with this Contract.
10.10 Termination for Convenience.
In terminating in accordance with 2 CFR Part 200, Appendix 11, this Contract may be
terminated in whole or in part only as follows:
10.10.1 By City with the consent of Agency in which case the Parties shall agree upon
the termination conditions, including the effective date and in the case of partial termination, the
portion to be terminated; or
10.10.2 By Agency upon at least 30 days written notification to City, setting forth the
reasons for such termination, the effective date, and in the case of partial termination, the portion
to be terminated. In the case of a partial termination, City may terminate the Contract in its
entirety if City determines in its sole discretion that the remaining portion of the Contract to be
performed or HOPWA Funds to be spent will not accomplish the purposes for which the Contract
was made.
10.11 Dissolution of Agency Terminates Contract.
This Contract shall terminate in the event Agency is dissolved or ceases to exist. In the
event of termination under this Section, all HOPWA Funds are subject to repayment and/or City
may exercise all of its remedies under this Contract.
10.12 Reversion of Assets.
In the event this Contract is terminated with or without cause, all assets acquired by
Agency with the HOPWA Funds including cash, interest payments from loans or otherwise, all
outstanding notes, mortgages or other security instruments, any accounts receivable attributable to
the use of the HOPWA Funds, and any real or personal property owned by Agency that was
improved with the HOPWA Funds shall automatically transfer to City or to such assignee as City
may designate.
11. REPAYMENT OF HOPWA FUNDS.
All HOPWA Funds are subject to repayment in the event the Program does not meet the
requirements of this Contract or in the HOPWA Regulations. If Agency takes any action that
results in the City being required to repay all or any portion of the HOPWA Funds to HUD,
Agency agrees it will reimburse City for such repayment. If Agency takes any action that
results in City receiving a finding from HUD about the Program, whether or not repayment
of all or any portion of the HOPWA Funds is required of City, Agency agrees it will pay City
10% of the HOPWA Funds as liquidated damages. The Parties agree that City's damages in
the event of either repayment to HUD being required or receiving a finding from HUD are
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uncertain and would be difficult to ascertain and may include an impact on City's HOPWA grant
or other federal grant funds, in addition to the finding by HUD or a required repayment of funds to
HUD by City. Therefore, the Parties agree that payment under this Section of 10% of the
HOPWA Funds by Agency to City is liquidated damages and not a penalty.
12. CHANGE IN NON-PROFIT STATUS.
Agency must provide City with written notification of any changes to its non-profit status
within 15 calendar days of being notified of the change. If the non-profit status of Agency changes
after the date of this Contract, City may but is not obligated to, terminate this Contract. City has
30 calendar days to make such determination after receipt of written notice from Agency and
failure to make such determination will constitute a waiver. In the event of termination under this
Section 12, all HOPWA Funds awarded but not yet paid to Agency pursuant to this Contract shall
be immediately rescinded and Agency shall have no further right to such funds. Any HOPWA
Funds already paid to Agency must be repaid to City within 30 calendar days of termination under
this Section.
13. SURVIVAL.
Any provision of this Contract that pertains to auditing, monitoring, client income
eligibility, record keeping and reports, City ordinances, or applicable HOPWA requirements, and
any default and enforcement provisions necessary to enforce such provisions, shall survive the
termination of this Contract for 5 years after the Contract term ends and shall be enforceable by
City against Agency. For purposes of this Contract, this 5 year period for survival of certain
Contract provisions is deemed to begin on October 1, 2016 and end on September 30, 2021
regardless of whether or not this Contract is earlier terminated.
14. GENERAL PROVISIONS.
14.1 Agency an Independent Contractor.
Agency shall operate hereunder as an independent contractor and not as an officer, agent,
servant or employee of City. Agency shall have exclusive control of, and the exclusive right to
control, the details of the work and services performed hereunder, and all persons performing
same, and shall be solely responsible for the acts and omissions of its officers, members, agents,
servants, employees, contractors, subcontractors, vendors, clients, licensees or invitees.
14.2 Doctrine of Respondeat Superior.
The doctrine of respondeat superior shall not apply as between City and Agency, or its
officers, members, agents, servants, employees, contractors, subcontractors, vendors, clients,
licensees or invitees, and nothing herein shall be construed as creating a partnership or joint
enterprise between City and Agency. City does not have the legal right to control the details of the
tasks performed hereunder by Agency, its officers, members, agents, employees, contractors,
subcontractors, vendors, clients, licensees or invitees.
14.3 Agency Property.
City shall under no circumstances be responsible for any property belonging to Agency, or
its officers, members, agents, employees, contractors, subcontractors, vendors, clients, licensees or
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invitees that may be lost, stolen or destroyed or in any way damaged and AGENCY HEREBY
INDEMNIFIES AND HOLDS HARMLESS CITY AND ITS OFFICERS, AGENTS, AND
EMPLOYEES FROM ANY AND ALL CLAIMS OR SUITS PERTAINING TO OR
CONNECTED WITH SUCH PROPERTY.
14.5 Religious Organization.
No portion of the HOPWA Funds shall be used in support of any sectarian or religious
activity. In addition, there must be no religious or membership criteria for clients of a HOPWA-
funded service.
14.6 Venue.
Venue shall lie in Tarrant County, Texas for any action, whether real or asserted, at law or
in equity, arising out of the execution, performance, attempted performance or non-performance of
this Contract.
_ 14.7 Governing Law.
This Contract shall be governed by and construed in accordance with the laws of the State
of Texas. If any action, whether real or asserted, at law or in equity, arises out of the execution,
performance or non-performance of this Contract or on the basis of any provision herein, for any
issue not governed by federal law, the choice of law shall be the laws of the State of Texas.
14.8 Severability.
The provisions of this Contract are severable, and if for any reason a clause, sentence,
paragraph or other part of this Contract shall be determined to be invalid by a court or federal or
state agency, board or commission having jurisdiction over the subject matter thereof, such
invalidity shall not affect other provisions which can be given effect without the invalid provision.
14.9 Written Agreement Entire Contract.
This written instrument and the Exhibits, Attachments, and Addendums attached hereto,
which are incorporated by reference and made a part of this Contract for all purposes, constitute
the entire agreement by the Parties concerning the work and services to be performed under this
Contract. Any prior or contemporaneous oral or written agreement which purports to vary the
terms of this Contract shall be void. Any amendments to the terms of this Contract must be in
writing and executed by the Parties.
14.10 Paragraph Headings for Reference Only, No Legal Significance; Number
and Gender.
The paragraph headings contained herein are for convenience in reference to this Contract
and are not intended to define or to limit the scope of any provision of this Contract. When
context requires, singular nouns and pronouns include the plural and the masculine gender shall be
deemed to include the feminine or neuter and the neuter gender to include.the masculine and
feminine. The words "include" and "including" whenever used herein shall be deemed to be
followed by the words "without limitation".
14.11 Compliance With All Applicable Laws and Regulations.
Agency agrees to comply fully with all applicable laws and regulations that are currently in
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effect or that are hereafter amended during the performance of this Contract. Those laws include,
but are not limited to:
➢ HOPWA Regulations found in 24 CFR Part 574
➢ AIDS Housing Opportunity Act, as amended (42 USC 12901 et seq.)
➢ Title VI of the Civil Rights Act of 1964 (42 U.S.C. Sections 2000d et seq.) including
provisions requiring recipients of federal assistance to ensure meaningful access by
person of limited English proficiency
➢ The Fair Housing Act, Title VIII of the Civil Rights Act of 1968 (42 U.S.C. Sections
3601 etseq.)
➢ Executive Orders 11063, 11246 as amended by 11375 and 12086 and as supplemented
by Department of Labor regulations 41 CFR Part 60
➢ The Age Discrimination in Employment Act of 1967
➢ The Age Discrimination Act of 1975 (42 U.S.C. Sections 6101 et seq.)
➢ The Uniform Relocation Assistance and Real Property Acquisition Policies Act of 1970
(42 U.S.C. Sections 4601 et seq. and 49 CFR Part 24) ("URA")
➢ Section 504 of the Rehabilitation Act of 1973 (29 U.S.C. Sections 794 et seq.) and 24
CFR Part 8 where applicable
➢ National Environmental Policy Act of 1969, as amended, 42 U.S.C. Sections 4321 et
seq. ("NEPA") and the related authorities listed in 24 CFR Part 58.
➢ The Clean Air Act, as amended, (42 U.S.C. Sections 1251 et seq.) and the Clean Water
Act of 1977, as amended (33 U.S.C. Sections 1251 et seq.) and the related Executive
Order 11738. In no event shall any amount of the assistance provided under this
Contract be utilized with respect to a facility that has given rise to a conviction under
the Clean Air Act or the Clean Water Act.
➢ Immigration Reform and Control Act of 1986 (8 U.S.C. Sections 1101 et seq.)
specifically including the provisions requiring employer verifications of legal status of
its employees
➢ The Americans with Disabilities Act of 1990 (42 U.S.C. Sections 12101 et seq.), the
Architectural Barriers Act of 1968 as amended (42 U.S.C. Sections 4151 et seq.) and
the Uniform Federal Accessibility Standards, 24 CFR Part 40, Appendix A
➢ Regulations at 24 CFR Part 87 related to lobbying, including the requirement that
certifications and disclosures be obtained from all covered persons
➢ Drug Free Workplace Act of 1988 (41 U.S.C. Sections 701 et seq.) and 24 CFR Part 23,
Subpart F
➢ Executive Order 12549 and 24 CFR Part 5.105(c) pertaining to restrictions on
participation by ineligible, debarred or suspended persons or entities
➢ Section 6002 of the Solid Waste Disposal Act, as amended by the Resource
Conservation and Recovery Act
➢ Guidelines of the Environmental Protection Agency at 40 CFR Part 247
➢ For contracts and subgrants for construction or repair, Copeland "Anti-Kickback" act
(18 U.S.C. 874) as supplemented in 29 CFR Part 5
➢ For construction contracts awarded by Agency in excess of $2,000, and in excess of
$2,500 for other contracts which involve the employment of mechanics or laborers,
Sections 103 and 107 of the Contract Work Hours and Safety Standards Act (40 U.S.C.
327A 300) as supplemented by 29 CFR Part 5
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➢ Lead-Based Paint Poisoning Prevention Act (42 U.S.C. 4801 et seq.), as amended by
the Residential Lead-Based Paint Hazard Reduction Act of 1992 (42 U.S.C. 4851 et
seq.) and implementing regulations at 24 CFR Part 35, subparts A, B, M, and R
➢ Uniform Administrative Requirements, Cost Principles, and Audit Requirements for
Federal Awards, 2 CFR Part 200 et seq.
➢ Federal Funding Accountability and Transparency Act of 2006 ("FFATA") (Pub.L.
109-282, as amended by Section 6205(a) of Pub.L. 110-252 and Section 3 of Pub.L.
113-101)
➢ Federal Whistleblower Regulations, as contained in 10 U.S.C. 2409, 41 U.S.C. 4712,
10 U.S.C. 2324, 41 U.S.C. 4304 and 41 U.S.C. 4310.
14.11 HUD-Assisted Proiects and Employment and other Economic
Opportunities; Section 3 Requirements.
14.11.1 Requirement that Law Be Quoted in Covered Contracts. — Certain
_ Requirements Pertaining to Section 3 of the Housing and Urban
Development Act of 1968 as Amended (12 U.S.C. Sections 1701 et seq.) and
its Related Regulations at 24 CFR Part 135.
If the Program results in the creation of new employment, training, or contracting
opportunities on a contractor or subcontractor level resulting from the expenditure of the HOPWA
Funds, Agency shall comply with the following and will ensure that its contractors also comply. If
the work performed under this Contract is on a project assisted under a program providing direct
federal financial assistance from HUD, Section 3 of 24 CFR Part 135.38 ("Section 3") requires
that the following clause, shown in italics, be inserted in all covered contracts ("Section 3
Clause"):
Section to be quoted in covered contracts begins:
"A. The work to be performed under this contract is subject to the requirements
of Section 3 of Housing and Urban Development Act of 1968, as amended, 12
U.S.C. section 170]u (Section 3). The purpose of Section 3 is to ensure that
employment and other economic opportunities generated by HUD assisted or
HUD-assisted programs covered by Section 3, shall to the greatest extent feasible,
be directed to low- and very-low income persons, particularly persons who are
recipients of HUD assistance for housing.
B. The parties to this contract agree to comply with HUD's regulations in 24
CFR Part 135, which implement Section 3. As evidenced by their execution of this
contract, the parties to this contract certify that they are under no contractual or
other impediment that would prevent them from complying with the Part 135
regulations.
C. The contractor agrees to send to each labor organization or representative
of workers with which it has a collective bargaining agreement or other
understanding, if any, a notice advising the labor organization or workers'
representatives of the contractor's commitments under this Section 3 clause and
will post copies of the notice in conspicuous places at the work site where both
employees and applicants for training and employment positions can see the notice.
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The notice shall describe the Section 3 preference, shall set forth minimum number
and job titles subject to hire, availability of apprentice and training positions, the
qualifications for each; and the name and location of the person(s) taking
applications for each of the positions; and the anticipated date the work shall
begin.
D. The contractor agrees that it will include this Section 3 clause in every
subcontract to comply with regulation in 24 CFR Part 135, and agrees to take
appropriate action, as provided in an applicable provision of the subcontract or in
this Section 3 clause, upon finding that the subcontractor is in violation of the
regulations in 24 CFR Part 135. The contractor will not subcontract with any
subcontractor where it has notice or knowledge that the subcontractor has been
found in violation of regulations in 24 CFR Part 135.
E. The contractor will certify that any vacant employment positions, including
training positions that are filed: (1) after the contractor is selected but before the
contract is executed, and(2) with persons other than those to whom the regulations
of 24 CFR Part 135. The contractor will not subcontract with any subcontractor
where it has notice or knowledge that the subcontractor has been found in violation
of regulations in 24 CFR Part 135.
F. Noncompliance with HUD's regulation in 24 CFR Part 135 may result in
sanctions, termination of this contract for default, and debarment or suspension
from fitture HUD assisted contracts.
G. With respect to work performed in connection with Section 3 covered Indian
housing assistance, section 7(b) of the Indian Self-Determination and Education
Assistance Act (25 U.S.C. Section 450(e) also applies to the work to be performed
under this Contract. Section 7(b) requires that to the greatest extent feasible (i)
preference and opportunities for training and employment shall be given to Indians,
and (ii) preference in the award of contracts and subcontracts shall be given to
Indian organizations and Indian-owned Economic Enterprises. Parties to this
contract that are subject to the provisions of Section 3 and Section 7(b) agree to
comply with Section 3 to the maximum extent feasible, but not in derogation of
compliance with Section 7(b). "
Section to be quoted in covered contracts ends.
14.11.2 Auency Responsibilities for Section 3 Requirements.
City and Agency understand and agree that compliance with the provisions of Section 3,
the regulations set forth in 24 CFR Part 135, and all applicable rules and orders of HUD shall be a
condition of the federal financial assistance provided to the Program binding upon City and
Agency and their respective successors, assigns, contractors and subcontractors. Failure to fulfill
these requirements shall subject Agency and its contractors and subcontractors and their respective
successors and assigns to those sanctions specified by the grant agreement through which federal
assistance is provided and to such sanctions as are specified by 24 CFR Part 135. Agency's
responsibilities include:
14.11.2.1 Implementing procedures to notify Section 3 residents and business
concerns about training, employment, and contracting opportunities
generated by Section 3 covered assistance;
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14.11.2.2 Notifying potential contractors working on Section 3 covered
projects of their responsibilities;
14.11.2.3 Facilitating the training and employment of Section 3 residents and
the award of contracts to Section 3 business concerns;
14.11.2.4 Assisting and actively cooperating with the HED Department in
making contractors and subcontractors comply;
14.11.2.5 Refraining from entering into contracts with contractors that are in
violation of Section 3 regulations;
14.11.2.6 Documenting actions taken to comply with Section 3; and
14.11.2.7 Submitting Section 3 Annual Summary Reports (Form HUD-60002)
in accordance with 24 CFR Part 135.90.
14.11.3 Section 3 Reporting Requirements.
In order to comply with the Section 3 requirements, Agency must submit the forms
attached hereto as EXHIBIT "G" - Section 3 Reporting Forms.
14.11.3.1 Report to the City on a quarterly basis all applicants for employment,
and all applicants for employment by contractor and subcontractor.
This shall include name, address, zip code, date of application, and
status (hired/not hired) as of the date of the report.
14.11.3.2 Advertise available positions to the public for open competition, and
provide documentation to City with the quarterly report that
demonstrates such open advertisement in the form of printout of
Texas Workforce Commission posting, copy of newspaper
advertisement, copy of flyers and listing of locations where flyers
were distributed, and the like.
14.11.3.3 Report to the City on a quarterly basis all contracts awarded by
contractor and subcontractor. This shall include name of contractor
and/or subcontractor, address, zip code, and amount of award as of
the date of the report.
14.12 Prohibition Against Discrimination.
14.12.1 General Statement.
Agency shall comply in the execution, performance or attempted performance of this
Contract, with all non-discrimination requirements of 24 CFR Part 574.603 and Chapter 17,
Article III, Division 4 —Fair Housing of the City Code. Agency may not discriminate against any
person because of race, color, sex, gender, religion, national origin, familial status, disability or
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perceived disability, sexual orientation, gender identity, gender expression, or transgender, nor will
Agency permit its officers, members, agents, employees, or clients to engage in such
discrimination.
This Contract is made and entered into with reference specifically to Chapter 17, Article
III, Division 3 - Employment Practices of the City Code, and Agency hereby covenants and agrees
that Agency, its officers, members, agents, employees and contractors, have fully complied with
all provisions of same and that no employee, or applicant for employment has been discriminated
against under the terms of such ordinances by either or its officers, members, agents, employees or
contractors.
14.12.2 No Discrimination in Employment during the Performance of This
Contract.
During the performance of this Contract Agency agrees to the following provision, and will
require that its contractors and subcontractors also comply with such provision by including it in
all contracts with its contractors:
[Contractor's Subcontractor's or Vendor's name] will not unlawfully discriminate against
any employee or applicants for employment because of race, color, sex, gender, religion, national
origin, familial status, disability or perceived disability, sexual orientation, gender identity, gender
expression or transgender. [Contractor's Subcontractor's or Vendor's name will take affirmative
action to ensure that applicants are hired without regard to race, color, sex, gender, religion,
national origin, familial status, disability or perceived disability, sexual orientation, gender
identity, gender expression or transgender and that employees are treated fairly during employment
without regard to their race, color, sex, gender, religion, national origin, familial status, disability
or perceived disability, sexual orientation, gender identity, gender expression or transgender. Such
action shall include, but not be limited to, the following: employment, upgrading, demotion or
transfer, recruitment or recruitment advertising, layoff or termination, rates of pay or other forms
of compensation, and selection for training, including apprenticeship. [Contractor's,
Subcontractor's or Vendor's name] agrees to post in conspicuous places, available to employees
and applicants for employment, notices setting forth the provisions of this nondiscrimination
clause.
[Contractor's Subcontractor's or Vendor's name] will, in all solicitations or advertisements
for employees placed by or on behalf of [Contractor's Subcontractor's or Vendor's name], state
that all qualified applicants will receive consideration for employment without regard to race,
color, sex, gender, religion, national origin, familial status, disability or perceived disability, sexual
orientation, gender identity, gender expression or transgender.
[Contractor's, Subcontractor's or Vendor's name] covenants that neither it nor any of its
officers, members, agents, employees, or contractors, while engaged in performing this Contract,
shall, in connection with the employment, advancement or discharge of employees or in
connection with the terms, conditions or privileges of their employment, discriminate against
persons because of their age or because of any disability or perceived disability, except on the
basis of a bona fide occupational qualification, retirement plan or statutory requirement.
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[Contractor's, Subcontractor's or Vendor's name] further covenants that neither it nor its
officers, members, agents, employees, contractors, or persons acting on their behalf, shall specify,
in solicitations or advertisements for employees to work on this Contract, a maximum age limit for
such employment unless the specified maximum age limit is based upon a bona fide occupational
qualification, retirement plan or statutory requirement.
14.12.3 Auency's Contractors and the ADA.
In accordance with the provisions of the Americans With Disabilities Act of 1990
("ADA"), Agency warrants that it and any of its contractors will not unlawfully discriminate on
the basis of disability in the provision of services to the general public, nor in the availability,
terms and/or conditions of employment for applicants for employment with, or employees of,
Agency or any of its contractors. AGENCY WARRANTS IT WILL FULLY COMPLY WITH
THE ADA'S PROVISIONS AND ANY OTHER APPLICABLE FEDERAL, STATE AND
LOCAL LAWS CONCERNING DISABILITY AND WILL DEFEND, INDEMNIFY AND
HOLD CITY HARMLESS AGAINST ANY CLAIMS OR ALLEGATIONS ASSERTED BY
THIRD PARTIES, CONTRACTORS SUBCONTRACTORS, VENDORS OR AGENTS
AGAINST CITY ARISING OUT OF AGENCY'S AND/OR ITS CONTRACTORS',
SUBCONTRACTORS', VENDORS' OR AGENTS' OR THEIR RESPECTIVE
EMPLOYEES' ALLEGED FAILURE TO COMPLY WITH THE ABOVE-REFERENCED
LAWS CONCERNING DISABILITY DISCRIMINATION IN THE PERFORMANCE OF
THIS CONTRACT.
14.13. Conflicts of Interest and Violations of Criminal Law.
14.13.1 Astency Safeguards.
Agency shall establish safeguards to prohibit its employees, board members, advisors and
agents from using positions for a purpose that is or gives the appearance of being motivated by a
desire for private gain for themselves or others, particularly those with whom they have family,
business or other ties. Agency shall disclose to City any such conflict of interest or potential
conflict of interest, immediately upon discovery of such.
14.13.2 General Prohibitions Against Conflicts of Interest.
No employees, agents, consultants, officers or elected officials or appointed officials of
City or of Agency who exercise or have exercised any functions or responsibilities with respect to
activities assisted with HOPWA funds or who are in a position to participate in a decision-making
process or gain inside information with regard to these activities may utilize HOPWA services,
may obtain a financial interest or benefit from a HOPWA-assisted activity, or have an interest in
any contract, subcontract or agreement with respect thereto, or the proceeds thereunder, either for
themselves or those with whom they have family or business ties, during their tenure or for 1 year
thereafter, unless they are accepted in accordance with the procedures set forth at 24 CFR Part
574.625.
14.13.2.1 Agency shall establish conflict of interest policies for federal awards
including the CDBG Funds and shall disclose in writing potential
conflicts of interest to City as authorized by 2 CFR Part 200.112.
HOPWA PSA CONTRACT 2015-2016 Page 24
Tarrant County Samaritan House,Inc. Rev. 10.02.2015
14.13.3 Conflicts of Interest Involving Procurement.
The conflict of interest provisions of 24 CFR Part 85.36 and 24 CFR Part 84.42,
respectively, shall apply in the procurement of property and services by Agency. In all cases not
governed by those Sections, the provisions of 24 CFR Part 574.625 of the HOPWA Regulations
shall apply.
14.13.3.1 As more particularly described in 2 CFR Part 200.318, Agency shall
maintain and submit to City written standards of conduct covering
conflicts of interest and governing the performance of its employees
engaged in the selection, award, and administration of contracts. No
employee, officer, or agent may participate in the selection, award,
or administration of a contract supported by a federal award if he or
she has a real or apparent conflict of interest. The standards of
conduct must provide for disciplinary actions to be applied for
violations of such standards by officers, employees, or agents of
Agency.
14.13.3.2 The officers, employees, and agents of Agency shall neither solicit
nor accept gratuities, favors, or anything of monetary value from
contractors or parties to subcontracts.
14.13.3.3 Notwithstanding the prohibition contained in Section 14.13.3.2,
Agency may set standards of conduct for situations in which the
financial interest is not substantial or the gift is an unsolicited item of
nominal value. Such standards of conduct must provide for
disciplinary actions to be applied for violations of such standards by
Agency's officers, employees or agents.
14.13.3.4 Agency shall maintain written standards of conduct covering
organizational conflicts of interest. Organizational conflicts of
interest means that because of relationships with a parent company,
affiliate, or subsidiary organization, Agency is unable or appears to
be unable to be impartial in conducting a procurement action
involving a related organization.
14.13.3.5 Agency must maintain records sufficient to detail the history of
procurement. These records will include, but are not necessarily
limited to the following: rationale for the method of procurement,
selection of contract type, contractor selection or rejection, and the
basis for the contract price.
14.13.4 Disclosure of Conflicts of Interest.
In compliance with 2 CFR Part 200.112, Agency is required to timely disclose to City in
writing any potential conflict of interest.
14.13.5 Disclosure of Texas Penal Code Violations.
Agency affirms that it will adhere to the provisions of the Texas Penal Code which prohibit
bribery and gifts to public servants.
HOPWA PSA CONTRACT 2015-2016 Page 25
Tarrant County Samaritan House,Inc. Rev. 10.02.2015
14.13.6 Disclosure of Federal Criminal Law Violations.
In compliance with 2 CFR Part 200.113, Agency is required to timely disclose to City all
violations of federal criminal law involving fraud, bribery or gratuity violations potentially
affecting the Agency.
14.14 Subcontracting with Small and Minority Firms, Women's Business
Enterprises and Labor Surplus Areas.
14.14.1 For procurement contracts $50,000.00 or larger that are paid for, in part or in
full, with HOPWA Funds, Agency agrees to abide by City's policy to involve Minority Business
Enterprises and Small Business Enterprises and to provide them equal opportunity to compete for
contracts for construction, provision of professional services, purchase of equipment and supplies
and provision of other services required by City. Agency agrees to incorporate the City's BDE
Ordinance, and all amendments or successor policies or ordinances thereto, into all contracts and
subcontracts for procurement larger than $50,000.00 or larger that are paid for, in part or in full,
with the HOPWA Funds and will further require all persons or entities with which it so contracts to
comply with said ordinance.
14.14.2 It is national policy to award a fair share of contracts to disadvantaged business
enterprises ("DBEs"), small business enterprises ("SBEs"), minority business enterprises
("MBEs"), and women's business enterprises ("WBEs"). Accordingly, affirmative steps must be
taken to assure that DBEs, SBEs, MBEs, and WBEs are utilized when possible as sources of
supplies, equipment, construction and services.
14.14.2.1 In order to comply with federal reporting requirements, Agency must
submit the form attached hereto as EXHIBIT "I" — MBE
Reporting Form for each contract or subcontract with a value of
$10,000.00 or more paid or to be paid with the HOPWA Funds.
Agency shall submit this form by the date specified in EXHIBIT
"I"—MBE Reporting Form.
14.15 Other Laws.
The failure to list any federal, state or City ordinance, law or regulation that is applicable to
Agency does not excuse or relieve Agency from the requirements or responsibilities in regard to
following the law,nor from the consequences or penalties for Agency's failure to follow the law, if
applicable.
14.16 Assignment.
Agency shall not assign all or any part of its rights, privileges, or duties under this Contract
without the prior written approval of City. Any attempted assignment of same without approval
shall be void, and shall constitute a breach of this Contract.
14.17. Right to Inspect Agency Contracts.
It is agreed that City has the right to inspect and approve in writing any proposed contracts
between Agency and any contractor or vendor engaged in any activity in conjunction with this
HOPWA-funded Program prior to any charges being incurred.
HOPWA PSA CONTRACT 2015-2016 Page 26
Tarrant County Samaritan House, Inc. Rev. 10.02.2015
14.18 Force Maieure
If Agency becomes unable, either in whole or part, to fulfill its obligations under this
Contract due to acts of God, strikes, lockouts, or other industrial disturbances, acts of public
enemies, wars, blockades, insurrections, riots, epidemics, earthquakes, fires, floods, restraints or
prohibitions by any court, board, department, commission or agency of the United States or of any
States, civil disturbances, or explosions, or some other reason beyond Agency's control
(collectively, "Force Majeure Event"), the obligations so affected by such Force Majeure Event
will be suspended only during the continuance of such event. Agency will give City written notice
of the existence, extent and nature of the Force Majeure Event as soon as reasonably possible after
the occurrence of the event. Failure to give notice will result in the continuance of Agency's
obligation regardless of the extent of any existing Force Majeure Event. Agency will use
commercially reasonable efforts to remedy its inability to perform as soon as possible.
15. INDEMNIFICATION AND RELEASE.
AGENCY COVENANTS AND AGREES TO INDEMNIFY, HOLD HARMLESS
AND DEFEND, AT ITS OWN EXPENSE, CITY AND ITS OFFICERS, AGENTS,
SERVANTS AND EMPLOYEES FROM AND AGAINST ANY AND ALL CLAIMS OR
SUITS FOR PROPERTY LOSS OR DAMAGE AND/OR PERSONAL INJURY,
INCLUDING DEATH, TO ANY AND ALL PERSONS, OF WHATSOEVER KIND OR
CHARACTER, WHETHER REAL OR ASSERTED, ARISING OUT OF OR IN
CONNECTION WITH THE EXECUTION, PERFORMANCE, ATTEMPTED
PERFORMANCE OR NONPERFORMANCE OF THIS CONTRACT AND/OR THE
OPERATIONS, ACTIVITIES AND SERVICES OF THE PROGRAM DESCRIBED
HEREIN, WHETHER OR NOT CAUSED IN WHOLE OR IN PART, BY ALLEGED
NEGLIGENCE OF OFFICERS, AGENTS, SERVANTS, EMPLOYEES, CONTRACTORS
OR SUBCONTRACTORS OF CITY; AND AGENCY HEREBY ASSUMES ALL
LIABILITY AND RESPONSIBILITY OF CITY AND ITS OFFICERS, AGENTS,
SERVANTS, AND EMPLOYEES FOR ANY AND ALL CLAIMS OR SUITS FOR
PROPERTY LOSS OR DAMAGE AND/OR PERSONAL INJURY, INCLUDING DEATH,
TO ANY AND ALL PERSONS, OF WHATSOEVER KINDS OR CHARACTER,
WHETHER REAL OR ASSERTED, ARISING OUT OF OR IN CONNECTION WITH
THE EXECUTION, PERFORMANCE, ATTEMPTED PERFORMANCE OR
NONPERFORMANCE OF THIS CONTRACT AND/OR THE OPERATIONS,
ACTIVITIES AND SERVICES OF THE PROGRAM DESCRIBED HEREIN, WHETHER
OR NOT CAUSED IN WHOLE OR IN PART BY ALLEGED NEGLIGENCE OF
OFFICERS, AGENTS, SERVANTS, EMPLOYEES, CONTRACTORS OR
SUBCONTRACTORS OF CITY. AGENCY LIKEWISE COVENANTS AND AGREES TO
AND DOES HEREBY INDEMNIFY AND HOLD HARMLESS CITY FROM AND
AGAINST ANY AND ALL INJURY, DAMAGE OR DESTRUCTION OF PROPERTY OF
CITY, ARISING OUT OF OR IN CONNECTION WITH ALL ACTS OR OMISSIONS OF
AGENCY, ITS OFFICERS, MEMBERS, AGENTS, EMPLOYEES, CONTRACTORS,
SUBCONTRACTORS, INVITEES, LICENSEES, OR CLIENTS, OR CAUSED, IN
WHOLE OR IN PART, BY ALLEGED NEGLIGENCE OF OFFICERS, AGENTS,
SERVANTS, EMPLOYEES, CONTRACTORS OR SUBCONTRACTORS OF CITY.
HOPWA PSA CONTRACT 2015-2016 Page 27
Tarrant County Samaritan House,Inc. Rev. 10.02.2015
IT IS THE EXPRESS INTENTION OF THE PARTIES, BOTH AGENCY AND
CITY, THAT THE INDEMNITY PROVIDED FOR THIS SECTION INCLUDES
INDEMNITY BY AGENCY TO INDEMNIFY AND PROTECT CITY FROM THE
CONSEQUENCES OF CITY'S OWN NEGLIGENCE, WHETHER THAT NEGLIGENCE
IS ALLEGED TO BE THE SOLE OR CONCURRING CAUSE OF THE INJURY,
DAMAGE OR DEATH.
AGENCY AGREES TO AND SHALL RELEASE CITY, ITS AGENTS,
EMPLOYEES, OFFICERS AND LEGAL REPRESENTATIVES FROM ALL LIABILITY
FOR INJURY, DEATH, DAMAGE OR LOSS TO PERSONS OR PROPERTY
SUSTAINED IN CONNECTION WITH OR INCIDENTAL TO PERFORMANCE UNDER
THIS CONTRACT, EVEN IF THE INJURY, DEATH, DAMAGE OR LOSS IS CAUSED
BY CITY'S SOLE OR CONCURRENT NEGLIGENCE.
AGENCY SHALL REQUIRE ALL OF ITS CONTRACTORS AND
SUBCONTRACTORS TO INCLUDE IN THEIR CONTRACTS AND SUBCONTRACTS A
RELEASE AND INDEMNITY IN FAVOR OF CITY IN SUBSTANTIALLY THE SAME
FORM AS ABOVE.
16. WAIVER OF IMMUNITY BY AGENCY.
If Agency, as a charitable or nonprofit organization, has or claims an immunity or
exemption (statutory or otherwise) from and against liability for damages or injury, including
death, to persons or property, Agency hereby expressly waives its rights to plead defensively such
immunity or exemption as against City. This Section shall not be construed to affect a
governmental entity's immunities under constitutional, statutory or common law.
17. INSURANCE AND BONDING.
Agency will maintain coverage in the form of insurance or bond in the amount of
$420,063.00 to insure against loss from the fraud, theft or dishonesty of any of Agency's officers,
agents, trustees, directors or employees. The proceeds of such insurance or bond shall be used to
reimburse City for any and all loss of HOPWA Funds occasioned by such misconduct. To
effectuate such reimbursement, such fidelity coverage shall include a rider stating that
reimbursement for any loss or losses shall name the City as a Loss Payee.
Agency shall furnish to City in a timely manner, but not later than the Effective Date,
certificates of insurance as proof that it has secured and paid for policies of commercial insurance
as specified herein. If City has not received such certificates by the Effective Date, Agency shall
be in default of the Contract and City may, at its option, terminate the Contract.
Such insurance shall cover all insurable risks incident to or in connection with the
execution, performance, attempted performance or nonperformance of this Contract. Agency shall
maintain the following insurance coverage and limits:
Commercial General Liability(CGL) Insurance
$ 500,000 each occurrence
$1,000,000 aggregate limit
HOPWA PSA CONTRACT 2015-2016 Page 28
Tarrant County Samaritan House,Inc. Rev. 10.02.2015
Non-Profit Organization Liability or Directors & Officers Liability
$1,000,000 Each Occurrence
$1,000,000 Annual Aggregate Limit
Business Automobile Liability Insurance
$1,000,000 each accident on a combined single-limit basis, or
$ 250,000 Property Damage
$ 500,000 Bodily Injury per person per occurrence
$2,000,000 Aggregate
Insurance policy shall be endorsed to cover"Any Auto", defined as autos owned, hired,
and non-owned. Pending availability of the above coverage and at the discretion of
City, the policy shall be the primary responding insurance policy versus a personal
auto insurance policy if or when in the course of Agency's business as contracted
herein.
Workers' Compensation Insurance
Part A: Statutory Limits
Part B: Employer's Liability
$100,000 each accident
$100,000 disease-each employee
$500,000 disease-policy limit
Note: Such insurance shall cover employees performing work on any and all projects
including but not limited to construction, demolition, and rehabilitation. Agency or its
contractors shall maintain coverages, if applicable. In the event the respective contractors
do not maintain coverage, Agency shall maintain the coverage on such contractor, if
applicable, for each applicable contract.
Additional Requirements
Such insurance amounts shall be revised upward at City's reasonable option and no more
frequently than once every 12 months, and Agency shall revise such amounts within 30 days
following notice to Contractor of such requirements.
Agency will submit to City documentation that it has obtained insurance coverage and has
executed bonds as required in this Contract prior to payment of any monies provided hereunder.
Where applicable, insurance policies required herein shall be endorsed to include City as an
additional insured as its interest may appear. Additional insured parties shall include employees,
officers, agents, and volunteers of City.
Any failure on part of City to request certificate(s) of insurance shall not be construed as a waiver
of such requirement or as a waiver of the insurance requirements themselves.
HOPWA PSA CONTRACT 2015-2016 Page 29
Tarrant County Samaritan House,Inc. Rev. 10.02.2015
Insurers of Agency's insurance policies shall be licensed to do business in the state of Texas by the
Department of Insurance or be otherwise eligible and authorized to do business in the state of
Texas. Insurers shall be acceptable to City insofar as their financial strength and solvency and
each such company shall have a current minimum A.M. Best Key Rating Guide rating of A-: VII
or other equivalent insurance industry standard rating otherwise approved by City.
Deductible limits on insurance policies shall not exceed $5,000 per occurrence unless otherwise
approved by City.
In the event there are any local, federal or other regulatory insurance or bonding requirements for
the Program, and such requirements exceed those specified herein, the former shall prevail.
Agency shall require its contractors to maintain applicable insurance coverages, limits, and other
requirements as those specified herein; and Agency shall require its contractors to provide Agency
with certificate(s) of insurance documenting such coverage. Also, Agency shall require its
contractors to have City and Agency endorsed as additional insureds (as their interest may appear)
on their respective insurance policies.
Directors and Officers Liability coverage shall be in force and may be provided on a claims-made
basis. This coverage may also be referred to as Management Liability, and shall protect the
insured against claims arising out of alleged errors in judgment, breaches of duty and wrongful
acts arising out of their organizational duties. Coverage shall protect not only the entity, but all
past, present and future directors, officers, trustees, employees, volunteers and committee
members.
Notwithstanding any provision in this Contract to the contrary, when applicable, Agency
shall comply with the requirements of 2 CFR 200.310 and shall, at a minimum, provide the
equivalent insurance coverage for real property and equipment acquired or improved with
CDBG Funds as provided to property owned by Agency.
18. CERTIFICATION REGARDING LOBBYING.
The undersigned representative of Agency hereby certifies, to the best of his or her
knowledge and belief, that:
No federal appropriated funds have been paid or will be paid, by or on behalf of Agency, to
any person for influencing or attempting to influence an officer or employee of any agency,
a member of Congress, an officer or employee of Congress in connection with the
awarding of any federal contract, the making of any federal grant, the making of any
federal loan, the entering into of any cooperative agreement and the extension,
continuation, renewal, amendment, or modification of any federal contract, grant, loan or
cooperative agreement.
If any funds other than federally appropriated funds have been paid or will be paid to any
person for influencing or attempting to influence an officer or employee of any agency,
member of Congress in connection with this federal contract, grant, loan or cooperative
HOPWA PSA CONTRACT 2015-2016 Page 30
Tarrant County Samaritan House,Inc. Rev. 10.02.2015
agreement, Agency shall complete and submit Standard Form-LLL, "Disclosure Form to
Report Lobbying," in accordance with its instructions.
This certification is a material representation of fact upon which reliance was placed when
this Contract was made or entered into. Submission of this certificate is a prerequisite for
making or entering into this Contract imposed by 31 U.S.C. Section 1352. Any person who
fails to file the required certification shall be subject to a civil penalty of not less than
$10,000.00 and not more than$100,000.00 for each such failure.
Agency shall require that the language of this certification be included in all subcontracts or
agreements involving the expenditure of federal funds.
19. LITIGATION AND CLAIMS.
Agency shall give City immediate notice in writing of any action, including any proceeding
before an administrative agency, filed against Agency in conjunction with this Contract or the
Program. Agency shall furnish immediately to City copies of all pertinent papers received by
Agency with respect to such action or claim. Agency shall provide a notice to City within 10 days
upon filing under any bankruptcy or financial insolvency provision of law.
20. NOTICE
All notices required or permitted by this Contract must be in writing and are deemed
delivered on the earlier date of the date actually received or the third day following deposit in a
United States Postal Service post office or receptacle; with proper postage, certified mail return
receipt requested; and addressed to the other Party at the address set out below or at such other
address as the receiving Party designates by proper notice to the sending Party.
City:
City Attorney's Office
1000 Throckmorton Street
Fort Worth, TX 76102
Telephone: 817-392-7600
Copy to:
Director of Neighborhood Services Department
1000 Throckmorton Street
Fort Worth, TX 76102
Attention: Assistant Director
Telephone: 817-392-7540
Copy to:
Director of Neighborhood Services Department
1000 Throckmorton Street
Fort Worth, TX 76102
Attention: Program Coordinator
Telephone: 817-392-6342
HOPWA PSA CONTRACT 2015-2016 Page 31
Tarrant County Samaritan House,Inc. Rev. 10.02.2015
Astency:
Tarrant County Samaritan House, Inc.
Lyn Scott
929 Hemphill Street
Fort Worth, TX 76104
Telephone: 817-332-6410
21. AGENCY HAS LEGAL AUTHORITY TO ENTER INTO CONTRACT.
Agency represents that it possesses the legal authority, pursuant to any proper,
appropriate and official motion, resolution or action passed or taken, to enter into this Contract
and to perform the responsibilities herein required.
22. COUNTERPARTS.
This Contract may be executed in multiple counterparts, each of which shall be
considered an original, but all of which shall constitute one instrument which may be sufficiently
evidenced by one counterpart.
[SIGNATURES APPEAR ON NEXT PAGE]
HOPWA PSA CONTRACT 2015-2016 Page 31-1
Tarrant County Samaritan House, Inc. Rev. 10.02.2015
IN WITNESS WHEREOF, the Parties hereto have executed 4 duplicate originals of this
Contract in Fort Worth, Tarrant County, Texas.
ATTEST: CITY OF FORT WORTH
By:
City Secretary Fernando Costa, Assistant City Manager
M&C: G-18521
Date: August 4, 2015
APPROVED AS TO FORM AND LEGALITY:
Assistant City Attorney
TARRANT COUNTY SAMARITAN HOUSE,
INC.
By: _ I/"
Name: 1'
Title:
CITY SECRE"FARY
i 'K WODRTH, 77
HOPWA PSA CONTRACT 2015-2016 Page 32
Tarrant County Samaritan House,Inc. Rev. 09.01.2015
IN WITNESS WHEREOF, t e Parties hereto have executed 4 duplicate originals of this Contract
in Fort Worth, Tarr t C 'o" "loco
A> ST; �� �� CITY OF FORT WORTH
�� �.,........,.m�,.
f � ca r`
By:
Ci c ry � t n Fernando Costa, Assistant City Manager
M&C.° -18521 �' '� `�°
AS
Date: August 4, 2015 `
APPROVED AS TO FORM AND LEGALITY:
F
Assistant City Attorney
TARRANT COUNTY SAMARITAN HOUSE,
INC.
By:
Name: Norbert White
Title: President/CEO
()FFICIAK.RECORD)
C,mIIr Y 3E"nC REVOLR '„
HOPWA PSA CONTRACT 2015-2016 Page 32
Tarrant County Samaritan House, Inc. Rev. 10.02.2015
EXHIBITS:
EXHIBIT "A"—Program Summary
EXHIBIT "A-1"—2015 HUD Income Limits
EXHIBIT "A-2" - Requirements for Completion of"Getting to Work Training Curriculum"
EXHIBIT "B"—Budget
EXHIBIT "C" —Audit Certification Form
EXHIBIT "D" —Reimbursement Forms
EXHIBIT "E" —Form of Income Self-Certification
EXHIBIT "F"—Standards for Complete Documentation
EXHIBIT "G" —Section 3 Reporting Forms
EXHIBIT "H" —Overview Report
EXHIBIT "I"—MBE Reporting Form
HOPWA PSA CONTRACT 2015-2016 Page 33
Tarrant County Samaritan House,Inc. Rev. 10.02.2015
EXHIBITS:
EXHIBIT "A"—Program Summary
EXHIBIT "A-1"—2015 HUD Income Limits
EXHIBIT "A-2" -Requirements for Completion of"Getting to Work Training Curriculum"
EXHIBIT "B"—Budget
EXHIBIT "C"—Audit Certification Form
EXHIBIT "D"—Reimbursement Forms
EXHIBIT "E"—Form of Income Self-Certification
EXHIBIT "F"—Standards for Complete Documentation
EXHIBIT "G"—Section 3 Reporting Forms
EXHIBIT "H"—Overview Report
EXHIBIT "I"—MBE Reporting Form
HOPWA PSA CONTRACT 2015-2016 Page 33
Tarrant County Samaritan House,Inc. Rev. 09.01.2015
TARRANT COUNTY SAMARITAN HOUSING, INC. EXHIBIT "A"
Samaritan House Supportive Services PROGRAM SUMMARY
PROGRAM SUMMARY
(HOPWA)
October 1, 2015 to September 30, 2016 $420,063.00
PERIOD AMOUNT
Capitalized terms not defined herein shall have meanings assigned them in the Contract.
PROGRAM:
The Program provides supportive services to HOPWA Eligible Clients living in the Samaritan
Villages Apartments, the Samaritan House Single Room Occupancy ("SRO") Facility, and in
scattered-site rental-voucher supported housing. The supportive services include case
management and housing counseling. Program services may also include congregate meals;
medical case management; substance abuse counseling; medical transportation; recreational and
social programs; educational programs; and life and job skills programs.
HOPWA Funds will be used to pay for a percentage of supportive service salaries, fringe
benefits, supplies, and contract labor associated with the Program. HOPWA Funds will also be
used to pay for the operational expenses of the Agency's SRO Facility located at 929 Hemphill
Street, Fort Worth, TX 76104. Operational expenses consist of but are not limited to salaries and
fringe benefits for property management and maintenance staff.
No more than 7% of the HOPWA Funds will be used to pay for administrative costs, including
salaries and fringe benefits, City-required insurance, taxes, and legal/accounting fees associated
with the Program.
Agency's office and Program services will be available at 929 Hemphill Street, Fort Worth,
Texas 76104, Monday through Friday, 9:00 a.m. to 5:00 p.m. Program services may also be
provided at clients' homes. The SRO is staffed 24 hours a day, 7 days a week.
The Program will be provided services to HOPWA Eligible clients residing in Tarrant, Johnson,
Parker, Wise, Hood and Somervell counties.
REGULATORY CLASSIFICATION:
IDIS matrix Code(s) and Service Category: 31D HOPWA Project Sponsor Administration
3 1 C HOPWA Project Sponsor Activity
Regulatory Citation(s): 24 CFR 574.300(b)(10)—Administrative Expenses
24 CFR 574.300(b)(7)—Supportive Services
24 CFR 574.300(b)(8) Facility Based Operations
HOPWA PSA CONTRACT 2015-2016—EXHIBIT"A"—PROGRAM SUMMARY Page I
Tarrant County Samaritan Housing,Inc.
Agency will maintain documentation which verifies that 100% of clients served by the Program
are eligible under HOPWA Regulations.
PROGRAM GOALS:
Minimum Number of Clients to be Served: The Program must provide Supportive Services to
a minimum of 160 Unduplicated Clients. Unduplicated Clients must be a resident of Tarrant,
Johnson, Parker, Wise, Hood and Somervell counties as shown by the monthly reports on
Attachment III. The Program will also provide Facility Based Housing Subsidy Assistance
through the housing operations of 60 household housing units.
HOPWA PSA CONTRACT 2015-2016—EXHIBIT"A"—PROGRAM SUMMARY Page 2
Tarrant County Samaritan Housing,Inc.
EXHIBIT "A-1"
2015 HUD INCOME LIMITS
2015 Median Family Income -Fort Worth/Arlington, TX*
1 Person 2 Persons 3 Persons 4 Persons 5 Persons 6 Persons 7 Persons 8 Persons
30%AMI $14,650 $16,750 $20,090 $24,250 $28,410 $32,570 $36,730 $40,890
50%AMI $24,400 $27,900 $31,400 $34,850 $37,650 $40,450 $43,250 $46,050
80%AMI $39,050 $44,600 1 $50,200 1 $55,750 1 $60,250 1 $64,700 $69,150 $73,600
*Income limits are published at least annually by HUD.
HOPWA PSA CONTRACT 2015-2016--EXHIBIT"A-1"—2015 HUD INCOME LIMITS Page 1
Tarrant County Samaritan Housing,Inc.
EXHIBIT "A-2"
REQUIREMENTS FOR COMPLETION OF "GETTING TO WORK TRAINING
CURRICULUM"
HOPWA PSA CONTRACT 2015-2016 Page I
EXHIBIT"A-2"REQUIREMENTS FOR COMPLETION OF"GETTING TO WORK TRAINING CURRICULUM"
Tarrant County Samaritan House,Inc.
Getting to Work:
A Training Curriculum for HIV/AIDS Service Providers and Housing Providers
At least 1 Agency employee must complete this required training curriculum by the deadline of April 15,
2016. Proof of completion must be submitted with the April reimbursement request.
The Getting to Work Training Curriculum is divided into 3 online modules:
Module 1: Understanding the Value of Work
Module 2: Adopting an Employment and Training Mindset—Organizationally and Individually
Module 3: Incorporating Employment into the HIV/AIDS Service Menu
To view the modules:
1. Click the module title.
2. You will be prompted to either create or log into your HUD Exchange Learn account.
3. Follow this guidance when creating a HUD Exchange account:
Step 1 of 2 screen: Fill out the required Personal Information, and Login Information sections. For the
Organization Information, if you are not affiliated with a HUD program, choose None of the Above
and I am an Individual.
Step 2 of 2 screen: All HUD Program Experience fields on the Learner Profile page are optional.
Click Update to complete the account creation process.
4. After creating an account or logging in, you will enter the HUD Exchange Learn system.
5. Click the Enroll button on the HUD Exchange Learn course description to access the course.
6. The module name will appear under Activities. Click the Module Name to access the course.
7. The module will launch in a new window, so please make sure your pop-up blockers are turned off.
To receive credit for completing each module•
1. Take the completion quiz under Activities on the HUD Exchange Learn course description. Each
module has a quiz.
2. Score 80% or better on the quiz. You may take the quiz multiple times.
3. After you pass the quiz, you will be able to print a completion certificate on the HUD Exchange
Learn course description.
You can access information about the modules by visiting the HUD Exchange website at
www.hudexchan�4e.com com or by using the following link: https://www.hudexchange.info/training-events/dol-
hud-getting-to-work-curriculum-for-hiv-aids-providers. You may also contact your assigned contract
administrator to get additional information.
HOPWA PSA CONTRACT 2015-2016 Page 2
EXHIBIT"A-2"REQUIREMENTS FOR COMPLETION OF"GETTING TO WORK TRAINING CURRICULUM"
Tarrant County Samaritan House, Inc.
EXHIBIT "B"-BUDGET
Grant` A(Tarrant ..B`(Pr�vatez C
Account TOTAL ,;
33uU et Cozennlzdrn �,. 1 ,...
ADMINISTRATIV (HUPWA ONLY)
Salaries 1001 16,195 34,880 317,249 368,324
FICA 1002 1,239 2,668 24,270 28,177
Life Insurance 1003 12 348 3,178 3,538
Health Insurance 1004 1,509 4,186 38,070 43,765
Disability Insurance 1005 0 0 0 0
Unemployment-State 1006 324 1,046 9,517 10,887
Workers Compensation 1007 69 151 1,372 1,592
Contract Labor-Accounting 1008 0 0 0 0
TOTAL ADMINISTRATIVE EXPENSES 19,348 43,279 393,656 456,283
4.6%
SUPPORTIVE SERVICE
PROGRAM PERSONNEL
Salaries 2001 225,419 225,735 151,559 602,713
FICA 2002 17,245 17,269 11,594 46,108
Life Insurance 2003 318 312 209 839
Health Insurance 2004 38,843 38,897 26,116 103,856
Unemployment 2005 4,508 451 3,031 7,990
Worker's Compensation 2006 5,467 5,475 3,676 14,618
Retirement 2007 0 0 0 0
SUPPLIES AND SERVICES
Office Supplies 3001 0 3,979 1,021 5,000
Office Equipment Rental 3002 0 2,400 2,400 4,800
Postage 3003 0 500 2,500 3,000
Printing 3004 0 500 4,500 5,000
MISCELLANEOUS
Construction/Building Materials(only REACH) 4001 0 0 0 0
Contract Labor-Accounting&IT
(City needs copy of contract before expenses
can be reimbursed) 4002 0 7,959 22,041 30,000
Craft Supplies 4003 0 0 0 0
Field Trip Admission Expenses 4004 0 0 0 0
Other Field Trip Expenses(if preapproved by
City) 4005 0 0 0 0
Food Supplies 4006 0 91,500 0 91,500
Teaching Aids 4007 0 0 0 0
FACILITY AND UTILITIES i
Telephone 5001 0 0 6,000 6,000
Electric 5002 0 0 12,000 12,000
Gas 5003 0 0 0 0
Water and Wastewater 5004 0 0 1,200 1,200
Solid Waste Disposal 5005 0 0 1,200 1,200
Rent(City needs copy of lease before expenses
can be reimbursed) 5006 0 0 0 0
Custodial Services 5007 1 0 0 11,300 11,300
Repairs 5008 0 0 6,000 6,000
Cleaning Supplies 5009 0 0 1,200 1,200
Building Security 5010 0 0 0 0
LEGAL,FINANCIAL,AND INSURANCE
Fidelity Bond or Equivalent 6001 500 0 0 500
Directors and Officers 6002 0 0 1,700 1,700
General Commercial Liability 6003 0 0 32,400 32,400
Contract Accounting 6004 1 806 0 0 806
Audit Fees 6005 1,500 0 10,000 11,500
TOTAL SUPPORTIVE SERVICE EXPENSES 294,606 394,977 311,647 1,001,230
DIRECT ASSISTANCE
Childcare Scholarships 7001 0 0 0 0
DIRECT ASSISTANCE�STRMU v
Short-term Rent Assistance 7002 0 0 0 0
HOPWA PSA CONTRACT 2015-2016-EXHIBIT"B"-BUDGET Page 1
Tarrant County Samaritan House,Inc.
Short-term Mortgage Assistance 7003 0 0 0 0
Short-term Utilities Assistance 7004 0 0 0 0
TOTAL STRMU EXPENSES 0 0 0 0
DIRECT ASSISTANCE—TBRA '
Tenant Based Rental Assistance 7005 0 232,659 0 232,659
TOTAL TBRA EXPENSES 0 232,659 0 232,269
FACILITY BASED OPERATION EXPENSES
Salaries 8001 86,433 87,759 57,736 231,928
FICA 8002 6,612 6,714 4,417 17,743
Life Insurance 8003 170 172 113 455
Health Insurance 8004 8,445 8,575 5,641 22,661
Disability Insurance 8005 0 0 0 0
Unemployment—State 8006 1,729 1,755 1,155 4,639
Worker's Compensation 8007 2,720 2,762 1,817 7,299
Accounting 8008 0 0 0 0
Retirement 8009 0 0 0 0
Insurance—Commercial Property and Liability,
Professional Liability 8010 0 0 0 0
TOTAL FACILITY BASED OPERATION
EXPENSES 106,109 107,737 1 70,879 284,725
BUDGET TOTAL; 420,063 778,652 776,182= 1;974;897
FUNDING A:TARRANT COUNTY
FUNDING B:PRIVATE FUNDING
FUNDING C:
HOPWA PSA CONTRACT 2015-2016—EXHIBIT"B"—BUDGET Page 2
Tarrant County Samaritan House, Inc.
The following tables were created for the purpose of preparing, negotiating, and determining the
cost reasonableness and cost allocation method used by the Agency for the line item budget
represented on the first page of this EXHIBIT "B" - Budget. The information reflected in the
tables is to be considered part of the terms and conditions of the Contract. Agency must have
prior written approval by the City to make changes to any line item in the Budget as outlined in
Section 5.2.2 in the Contract. The deadline to make changes to EXHIBIT "B" -Budget is June
1, 2016.
SALARY DETAIL-ADMINISTRATIVE
Position Name Rate Annual Hours Percent to Grant Amount to Grant
President/Chief Executive 106,624 2080 4% 4,265
Officer
Vice President and Chief 87,837 2080 8% 7,027
Operations Officer
Administrative Assistant- 23,673 2080 10% 2,367
Accounting
Grant Manager 42,271 2080 6% 2,536
TOTAL 260,405 6.2% 16,195
FRINGE DETAIL-ADMINISTRATIVE
Percent of Amount Percent to Grant Amount to Grant
Payroll
FICA 7.65% 19,921 6.22% 1,239
Life Insurance .076% 198 6.06% 12
Health Insurance 11% 27,552 5.477% 1,509
Disability Insurance 0% 0 0% 0
Unemployment 2% 5,208 6.22% 324
Workers Comp 0.4324% 1,126 6.13% 69
TOTAL 54,005 5.8% 3,153
MISCELLANEOUS -ADMINISTRATIVE
Total Budget Percent to Grant Amount to Grant
Contract Labor-Accounting 0
TOTAL 0
SALARY DETAIL- SUPPORTIVE SERVICES
Position Name Rate Annual Hours Percent to Grant Amount to Grant
Vice President and Chief 77,490 2080 17% 13,173
Program Officer
Food Service Manager 43,037 2080 27% 11,620
Cook 1 30,638 2080 55% 16,851
Cook 2 30,784 2080 56% 17,239
Cook 3 13,530 1333 53% 7,171
Medical Case Manager 62,400 2080 17% 10,608
Resident Care Coordinator 31,364 2080 34% 10,664
Resident Care Attendant 1 (RCA 24,960 2080 55% 13,728
1)
Resident Care Attendant 2(RCA 22,880 2080 61% 13,957
2)
Resident Care Attendant 3(RCA 11,440 1040 58% 6,635
HOPWA PSA CONTRACT 2015-2016-EXHIBIT"B"-BUDGET Page 3
Tarrant County Samaritan House, Inc.
3)
Resident Care Attendant 4(RCA 11,440 1040 61% 6,978
4)
Resident Care Attendant 5(RCA 5,720 520 89% 5,091
5)
Family Health and Education 47,000 2080 58% 27,260
Manager
Case Management Program 42,000 2080 11% 4,620
Manager/LCDC
Support Services Manager 39,690 2080 65% 25,799
Social Services Case Manager 1 40,000 2080 56% 22,400
Social Services Case Manager 2 37,500 2080 31% 11,625
TOTAL 571,873 39.4% 225,419
FRINGE DETAIL-SUPPORTIVE SERVICES
Percent of Amount Percent to Grant Amount to Grant
Payroll
FICA 7.65% 43,748 39.42% 17,245
Life Insurance .1384% 792 40% 318
Health Insurance 15.2177% 87,026 44.634% 38,843
Unemployment 2% 11,437 39.42% 4,508
Disability Insurance 0 0
Workers Compensation 2.214% 12,662 43.18% 5,467
Retirement 0 0
TOTAL 159,665 41.5% 66,381
FACILITY BASED OPERATION SALARY DETAIL
Position Name Rate Annual Percent to Amount to
Hours Grant Grant
Driver/Maintenance Manager 38,081 2080 60% 22,849
Property Manager 48,830 2080 86% 41,994
Administrative Assistant-Property Support 20,800 2080 30% 61240
Driver/Maintenance Technician 18,720 2080 82% 15,350
TOTAL 126,431 68.3% 86,433
FACILITY BASED OPERATION FRINGE DETAIL
Percent of Amount Percent to Amount to
Payroll Grant Grant
FICA 7.65% 9,672 68.36% 6,612
Life Insurance .0462% 264 64.44% 170
Health Insurance 2.9144% 16,667 50.67% 8,445
Disability Insurance 0% 0 0% 0
Unemployment-State .4422% 2,529 68.37 1,729
Worker's Compensation .7058% 4,036 67.39% 2,720
Retirement 0% 0 0% 0
Accounting 0% 0 0% 0
TOTAL 33,168 59.3% 19,676
FACILITY BASED OPERATION INSURANCE
Total Budget Percent to Amount to Grant
Grant
Commercial Property and Liability,Professional 22,778 0% 0
Liability
TOTAL 0
HOPWA PSA CONTRACT 2015-2016-EXHIBIT`B"-BUDGET Page 4
Tarrant County Samaritan House, Inc.
SUPPLIES AND SERVICES -SUPPORTIVE SERVICES
Total Budget Percent to Grant Amount to Grant
Office Supplies 5,000 0% 0
Office Equipment Rental 8,111 0% 0
Postage 3,000 0% 0
Printing 10,067 0% 0
Medical Supplies 8,250 0% 0
TOTAL 34,428 0
MISCELLANEOUS- SUPPORTIVE SERVICES
Total Budget Percent to Grant Amount to Grant
Contract Labor–IT 0
Contract Labor–Accounting 37,000 0% 0
Craft Supplies 0
Facility Fees 0
Field Trip Costs 0
Food Supplies 95,000 0% 0
Teaching Aids 0
TOTAL 132,000 0
FACILITY AND UTILITIES-SUPPORTIVE SERVICES
Total Budget Percent to Grant Amount to Grant
Telephone 6,000 0% 0
Electric 12,000 0% 0
Gas 0 0% 0
Water and Wastewater 1,200 0% 0
Solid Waste Disposal 1,200 0% 0
Rent 0 0% 0
Custodial Services 11,300 0% 0
Repairs 15,000 0% 0
Cleaning Supplies 1,200 0% 0
Building Security 0 0% 0
TOTAL 47,900 0
LEGAL, FINANCIAL AND INSURANCE-SUPPORTIVE SERVICES
Total Budget Percent to Grant Amount to Grant
Fidelity Bond(or Equivalent) 500 100% 500
Directors and Officers 2,360 0% 0
General Commercial Liability 3,033 26.57% 806
Contract Accounting 0 0% 0
Audit Fees 11,500 13.04% 1,500
Business Auto Insurance 4,039 0% 0
TOTAL 21,432 13% 2,806
DIRECT ASSISTANCE- STRMU
Total Budget Percent to Grant Amount to Grant
Short-Term Rent Assistance 0 0
Short Term Mortgage Assistance 0 0
Short Term Utilities Assistance 0 0
TOTAL 0 0
HOPWA PSA CONTRACT 2015-2016—EXHIBIT`B"—BUDGET Page 5
Tarrant County Samaritan House,Inc.
DIRECT ASSISTANCE-TBRA
Total Budget Percent to Grant Amount to Grant
Tenant Based Rental Assistance 232,000 0% 0
TOTAL 232,000 0
HOPWA PSA CONTRACT 2015-2016—EXHIBIT`B"—BUDGET Page 6
Tarrant County Samaritan House, Inc.
EXHIBIT "C"
AUDIT CERTIFICATION FORM
HOPWA PSA CONTRACT 2015-2016—EXHIBIT"C"—AUDIT CERTIFICATION FORM Page 1
Tarrant County Samaritan Housing,Inc.
AUDIT CERTIFICATION FORM AND AUDIT REQUIREMENTS
Agency: Tarrant County Samaritan Housing,Inc.
Fiscal Year Ending: September 30,2016
[During the fiscal year in which funds will be received, we will exceed the federal
expenditure threshold of $750,000. We will have our Single Audit or Program Specific
Audit completed and will submit the audit report described in 2 CFR Part 200 within 7
months after the end of the audited fiscal year or 30 days within its completion, whichever
is the earlier date.
❑ During the fiscal year in which funds will be received, we will not exceed the $750,000
federal expenditure threshold required for a Single Audit or a Program Specific Audit to be
performed this fiscal year. (Fill out schedule below)
Federal Expenditure Disclosure
MUST be filled out if Single Audit or Program Audit is NOT re uired.
Pass Through Program Name& Contract
"Federal Grantor Expenditures
Grantor CFDA Number Number
Total Federal Expenditures for this Fiscal Year:
i atory anh Title D to
Failure to submit this or a similar statement or failure to submit a completed single audit package
as described in the federally required audit requirements described in 2 CFR Part 200, as
applicable, by the required due date may result in suspension of funding and may affect
eligibility for future funding. Notwithstanding the above, this certification acknowledges the
agency's commitment to meet all other financial reporting, financial statements, and other
audit requirements as may be set forth in the Contract.
HOPWA PSA CONTRACT 2015-2016—EXHIBIT"C"—AUDIT CERTIFICATION FORM Page 2
Tarrant County Samaritan Housing,Inc.
EXHIBIT "D"
REPORTING FORMS
HOPWA PSA CONTRACT 2015-2016—EXHIBIT"D"—REPORTING FORMS Page 1
Tarrant County Samaritan Housing, Inc.
ATTACHMENT I
Invoice -Administration
INVOICE
HOPWA Administrative
Agency: Tarrant County Samaritan House, Inc.
Address: '
City, State, Zip: ,
Program: Samaritan House Supportive Services
Period of Service:' I
Program Amount
This Invoice Cumulative to Date'
Administrative
Agency's Certification: By signing this report, I certify to the best of my
knowledge and belief that the report is true, complete, and accurate, and
the expenditures, disbursements and cash receipts are for the purposes
and objectives set forth in the terms and conditions of the Federal award.
I am aware that any false, fictitious or fraudulent information, or the
omission of any material fact, may subject me to criminal, civil, or
administrative penalties for fraud, false statements, false claims, or
otherwise. U.S. Code Title 18, Sec. 1001 and Title 31, Sec. 3729-3730
and 3801-3812.
Signature and Date:
Name:
Title:'
HOPWA PSA CONTRACT 2015-2016—EXHIBIT"D"—REPORTING FORMS Page 2
Tarrant County Samaritan Housing, Inc.
ATTACHMENT I
Invoice—Supportive Services
INVOICE
HOPWA Supportive Services
Agency:; Tarrant County Samaritan House, Inc.
Address: I
City, State, Zip:
Program: Samaritan House Supportive Services '
Period of Service:'
Program Amount
This Invoice Cumulative to Date
Supportive Services
Agency's Certification: By signing this report, I certify to the best of my
knowledge and belief that the report is true, complete, and accurate, and
the expenditures, disbursements and cash receipts are for the purposes
and objectives set forth in the terms and conditions of the Federal award.
I am aware that any false, fictitious or fraudulent information, or the
omission of any material fact, may subject me to criminal, civil, or
administrative penalties for fraud, false statements, false claims, or
otherwise. U.S. Code Title 18, Sec. 1001 and Title 31, Sec. 3729-3730
and 3801-3812.
Signature and Date:
Name:
Title:
HOPWA PSA CONTRACT 2015-2016—EXHIBIT"D"—REPORTING FORMS Page 3
Tarrant County Samaritan Housing, Inc.
ATTACHMENT
Invoice—Facility Based Operations
INVOICE '
HOPWA Facility Based Operating Expenses
Agency:! Tarrant County Samaritan House, Inc.
Address:'
City, State, Zip:
Program: Samaritan House Supportive Services
Period of Service:
Program Amount
This Invoice " Cumutatiue#o Dat6
Facility Based
Operating Expenses
Agency's Certification: By signing this report, I certify to the best of my
knowledge and belief that the report is true, complete, and accurate, and
the expenditures, disbursements and cash receipts are for the purposes
and objectives set forth in the terms and conditions of the Federal award.
I am aware that any false, fictitious or fraudulent information, or the
omission of any material fact, may subject me to criminal, civil, or
administrative penalties for fraud, false statements, false claims, or
otherwise. U.S. Code Title 18, Sec. 1001 and Title 31, Sec. 3729-3730
and 3801-3812.
Signature and Date:
Name:
Title:
HOPWA PSA CONTRACT 2015-2016—EXHIBIT"D"—REPORTING FORMS Page 4
Tarrant County Samaritan Housing, Inc.
ATTACHMENT II
Expenditure Worksheet—Administration
HOP1VA Administrative
City of Fort North
Housing and Economic Development Department
Expenditure Wodcsheet
Agency:. Tarrant County Samaritan House,Inc.
Program:' Samaritan HOUSe Su rortice Sendees
Highlighted are the only relevant codes for this Program.
Please group like account codes.
Mcount j Code
;See Es)ienseLine Item
Lire Na. C1sckNo Descri ion* Key to Right) Amount Account
I ADMUMTRATIVE'HOPWA OnI
2 1'Salaries 1001
3 ?:FICA ''!1002
4 'Life lnumnce %1003 'r
5 Healthhtsumnce ".':1004
6 Disability Ins—o-- 1005
7 -'Uicm to niem-Stale "1006 <
8 Workers Coup 1007
9 PROGRAMPERSONNEL
10 Salaries 2001
11 FICA 2002
12 Life Ins—e 2003
13 Healthhrsurance 2004
14 Urem 10'-em 2005
15 Worker's 2006
16 Retirement 2007
17 SUPPLIES AND SERVICES
18 Office S.ppl ies 3001
19 OfBceE i ment Rental 3002
20 Posm a 3003
21 PfintinR 3004
22 MISCELLANEOUS=
23 ComtructiontBuildi Materials 4002
24 Contract Labor-Account; IT 4003
25 Craft Supplies 4004
26 Field Trip Admission& W
; ncs 4005
27 Food Supplies 4006
28 TeacNn Aids 4007
29 FACHSTYAND UTMTHES
30 Telephone 5001
31 Electric 5002
32 Gas 5003
33 Water and Wtetersater 5004
34 Solid Waste DisDasal 5005
35 Rent 5006
36 Custodial Services 5007
37 Re 'rs 5008
38 Cleanin Supplies 5009
39 Building Security 5010
40 LEGAIEINANCLU4 AND INSURANCE
41 Fidelity Bond or Equivalent 6001
42 Directors and Offi cers 6002
43 General Commercial Liability 6003
44 Contract Accounting 6004
45 Audit Fees 6005
46 DHIECTASSISTANCE
47 Childcare Scholarships 7001
48 DDIECTASSISTANCE=STRAIU':
49 Short-term Rent Assistance 7002
50 Short-term Mori L sistance 7003
51 Short-term Utilities Assistance 7004
52 DHIECTASSISTANCE-STRMU
53 Tenant Based Rental Assistance 7003
54 FACH31YBASED OPERATION EIsRENSES
55 Salaries 8001
56 FICA 8002
57 Life l sumnce 8003
58 Health heonance 8004
59 Disability Insumrce 8005
60 Urem to•ment-State 8006
Total Worker's Com•nation 8007
Accounting 8008
*Payroll most identify employee.Rent most rdentifv tenant.Other payments should identify individuals,ifapplicable Retirement 8009
-. ksmance 8010
HOPWA PSA CONTRACT 2015-2016—EXHIBIT"D"—REPORTING FORMS Page 5
Tarrant County Samaritan Housing, Inc.
ATTACHMENT II
Expenditure Worksheet—Supportive Services
HOPNA Support ive Services
City of Fort North -
Housing and Economic Development Department
Expenditure Nocksheet
Agency:! Tarrant Cr ty Samaritan House,Inc. _. _..
Program:! Samaritan House Snppa yc Services
Highlighted are the only relevant codes for this Program.
Please group like account codes.
Account Code(See Espene Line Item
Liao No. CheckNc, '..Puree 1)eseri ion*- key to Right) Amount Account
1 ADMINISTRATPM HOPNA Only
2 Sal:vies ]001
3 FICA 1002
4 Life Insurance 1003
5 Health lmsur:uce 1004
6 Disabilitv Insurance 1005
7 Urem lovment-State 1006
8 Lc &Accountin 1007
._..
9 PROCRA1tIPERSONNF.L
10 Salaries :::2001
11 `FICA '2002
12 `Life lnumrcc -2003
_ 13 Health lusurance ''2004
14 Urem torment 2005
15 Workers Compensation -2006
16 'Retirement ".2007 -
17 SUPPLIES AND SERVICES
18 Officesupplics 3001
19 Office ti—pt Rectal 3002
20 Posta a 3003
21 Printi 3004
22 MISCEI.L 11YEOUS
23 Construction1hrildine Materials 4002
24 Contract Labor-Accountin IT 4003
25 Crap Su lies 4004
26 Field Tri AdmissionF- nes 4005
27 Food Supplies 4006
28 T—Irmg Aids 4007
29 FACIIAW AND UTILUIES
30 Telc tpR: 5001
31 Electric 5002
32 Gas 5003
33 Water and Wastewater 5004
34 Solid Waste Disposal 5005
35 Rent 5006
36 Custodial Services 5007
37 Repairs 5008
38 Cleartmg Supplies 5009
39 Buildin Security 5010
40 LEGAIMANCLAI,AND INSURANCE
41 "Fidelity Bond or uisateat '6001
42 Directors—Officers 6002
43 General Commercial Liabilitv 61103
44 -:Contract Accoun in o
45 `Audit Fees 6005
46 DIRECTASSISTANCE
47 Childcare Scholarships7001
48 DIRECTASSiSTANCE-STRAIU
49 Short-term Rent Assistance 7002
50 Short-tertatmortgats,Assistance 7003
51 Short-temp Utilities Assistance 7004
52 DIRECT ASSISTANCE-STRAW
53 Temnt Based Renmal Assistance 7005
54 FACILITY RASED OPERATION EXTENSES
55 salaries 8001
56 FICA 8002
57 Life Insurance 8003
58 Health krsumnee 8004
59 Disability Inuraree 8005
60 Urem lornenu-State 8006
Total Worker's Com nation 8007
Acconnti 8008
"Payroll must identify employee.Rent must idmdify te—t Other payments should dereify individuals,ifapplicable. Retirement 1 8009
Insurance 8010
HOPWA PSA CONTRACT 2015-2016—EXHIBIT"D"—REPORTING FORMS Page 6
Tarrant County Samaritan Housing,Inc.
ATTACHMENT II
Expenditure Worksheet—Facility Based Operations
HOPNA Facility Based Operating Expenses
City of Fort North
Housing and Economic Development Department
Expenditure Worksheet
Agency: Tarrant Counts Samaritan House,Inc
Program:'. Samaritan House Supporth a Services
!. Highlighted are the only relevant codes for this Program.
Please group like account codes.
^. Account.Code(see -Expense Pine Item
L=' No. ChackN'o P ce Dmri ion*' Kee th Ri td) Amount
Account
1 ADAHNISTRATIVE`HOPWAOM
2 Salaries 1001
3 FICA 1002
4 Life Insurance 1003
5 Hea)Ihhrsurmrce 1004
6 Disability Inaomrne 1005
7 Urem loyanent-State 1006
8 Le &Accountin 1007
9 PROGRAMPERSONNEL
10 Salaries 2001
11 FICA 2002
12 Life lrsmance 2003
13 Health insurance 2004
14 Unemployment 2005
15 Nod:er's Com oration 2006
16 Rearemem 2007
17 SUPPLIES AND SERVICES'
18 Office Supplies 3001
19 Office Equipment Rental 3002
20 postage 3003
21 Printing 3004
22 MISCELLANEOUS
23 Cmstmctim✓Buildin Materials 4002
24 Contract Labor-Accoumi IT 4003
25 Cmft Supplies 4004
26 Field Trip Admission Ea nscs 4005
27 Food Su ties 4006
28 Teachm Aids 4007
29 FACITMAND U'1TrTI IES . ,
30 Tele lane 5001
31 Electric 5002
32 Gas 5003
33 Wmerand Walt-1cr 5004
34 Solid Waste Disposal 5005
35 Rent 5006
36 Custodial Senices 5007
37 Rc 'rs 5008
38 Cleaiun Su lies 5009
39 Buildine Sec i 5010
40 LEG'- FINANCLU AND INSURANCE
41 Fidelity Borden- uisalent 6001
42 Directors aid Officers 6002
43 General Commercial Liability 6003
44 Comrxt Accountin 6004
45 Audit Fees 6005
46 JHRECTASSISTANCE
47 Ctdldcaze Scholarshi 7001
48 DHiECTASSLSTANCE-STRhN
49 Short-term Rent Assistarce 7002
50 Short-tens Mortgage Assistancc 7003
51 Shan-term Utilities Assistance 7004
52 DIRECTASSISTANCE-STRMU `.
53 Tenant Based Rental Assistance 7005
54 FACHITY BASED OP£RATIONEXPENSES
55 Salaries '8001
56 `'FICA '8002
57 '-Life Laurance 1'.8003
58 `Health luarrame "8004
59 Disability Insurance 8005
60 Unemployment-State -.'8006 `?
Total Worker's Compensation "8007
Accounting 8008
*Payroll must identify employee.Rem must identify leant Otlar payments should identify fixihiduals,if applicable. Retirement 8009
hismmce 8010
HOPWA PSA CONTRACT 2015-2016—EXHIBIT"D"—REPORTING FORMS Page 7
Tarrant County Samaritan Housing,Inc.
ATTACHMENT III
Client Data Report—Supportive Services
1�nii i
_ Alcnc): Tarrant CovnU Samarvan House Ine.
PlOgiim: Samarpan i{Dote Suo ne Senie _ '..
�nd�ml uzmm��er+ mN�eaYVf �Rf m5:pm4rM aJ�r�®WP �roa a�m.r whrmrnm WNNnam 4mh sse a a.nf�a
101flYfY{lOf' i ftls • m 'uv�
)•atloWrapn i ua i fl tll !YJ eM1e Rd tlae im v ➢vfrt
npasrmNS'+nra+Mtlb.aaxncflaaemnmratdQ®ntrsmtnaomegfnibameapgre @mraneeagaetam a9ma2tsertnandy0sp.rwnaapa.mmmipapm W®uaoWa3d4Ni1nNMwm MemehopiWfNWrmrYw MmNlunl®a�
..em.a(aral�NCPE�1'31P.\'ill •FkssNFd 3f tll.arprtle®uh
4n•w), fls�cie) M4�@) �� N3FSmaeY e[rm5arrve) ...'
6GE,
� ssircaccN 5RF£!lII%ffi '..
zmevfl v'.:�v.^t, Y+.VE (�}eu) .. '. 4DSGV sxy 3tasE wawa mmi¢ 3i�f
;�A\'ME tzc YUwMA
532:- iM
HOPWA PSA CONTRACT 2015-2016—EXHIBIT"D"—REPORTING FORMS Page 8
Tarrant County Samaritan Housing, Inc.
EXHIBIT "E"
INCOME CERTIFICATION FORMS
HOPWA CONTRACT 2015-2016--EXHIBIT`B"--INCOME CERTIFICATION FORMS Page 1
Tarrant County Samaritan Housing,Inc.
Tarrant County Samaritan Housing,Inc.
CERTIFICATION OF INCOME STATEMENT
Applicant Name:
Current Address: Phone
Household Members and Income
(Including Applicant)
Last Name First Name Age Monthly Source/Employer Name
Income
"PERSONAL INFORMATION:(Check one in each item. Optional Information for Federal Reporting Purposes)
a. ❑MALE b.❑WHITE ❑BLACK/AFRICAN AMERICAN ❑BLACK/AFRICAN AMERICAN&WHITE
❑FEMALE ❑AMERICAN INDIAN/ALASKAN NATIVE ❑ASIAN
❑AMERICAN INDIAN/ALASKAN NATIVE&WHITE ❑ASIAN&WHITE
❑NATIVE HAWAIIAN/OTHER PACIFIC ISLANDER ❑BALANCE/OTHER
❑AMERICAN INDIAN/ALASKAN NATIVE&BLACK/AFRICAN AMERICAN
c. ETHNICITY d. DISABLED e. IS CLIENT WOMEN HEAD OF HOUSEHOLD
❑HISPANIC ❑YES ❑YES
❑NON-HISPANIC ❑NO ❑NO
* TOTAL NUMBER OF HOUSEHOLD MEMBERS (Include Yourself AND everyone who lives in the house.)
Total Anticipated Annual Household Income:
Certification:
I certify that the information I am providing is true and could be subject to verification at any time by a third
party. I also acknowledge that the provision of false information could leave me subject to the penalties of
Federal, State and local law.
WARNING: TITLE 18,SECTION IOOI OF THE U.S.CODE STATES THAT A PERSON IS GUILTY OF A FELONY
FOR KNOWINGLY AND WILLINGLY MAKING FALSE OR FRAUDULENT STATEMENTS TO ANY DEPARTMENT OF
THE UNITED STATES GOVERNMENT.
Signature of Applicant Date
-----------------For use by Agency staff only-----------------
Household Size: Gross Annual Income:
Applicable Income Limit: Is Applicant Eligible?
Check if Applicant refused to provide demographic information: ❑
Staff Assessment of Demographics:
Person Making Determination: Date:
NOTE. Address, income amounts and sources for ALL household members are required.
HOPWA CONTRACT 2015-2016--EXHIBIT"E"--INCOME CERTIFICATION FORMS Page 2
Tarrant County Samaritan Housing,Inc.
Tarrant County Samaritan Housing, Inc.
CERTIFICACION DE DECLARACION DE INGRESOS
Nombre del Solicitante:
Domicilio Actual: Numero de Telefono:
Miembros en el Ho ag r e In resos
(Incluir el/la solicitante)
Apellido Nombre Edad Ingreso Fuente de Ingresos/Nombre de Empleador
Mensual
**INFORMACI6N PERSONAL:(Seleccione uno en cada categoria. Informaci6n opcional para prop6sitos de informaci6n Federal)
a. ❑MASCULINO b. ❑CAUCASICO ❑NEGRO/AFRICANO AMERICANO
❑NEGRO/AFRICANO AMERICANO&CAUCASICO
❑FEMININO ❑INDIO AMERICANO/NATIVO DE ALASKA ❑ASIATICO
❑INDIO AMERICANO/NATIVO DE ALASKA&CAUCASICO ❑ASIATICO&CAUCASICO
❑NATIVO HAWAIANO/OTRO DE LAS ISLAS PACIFICAS ❑BALANCE/OTRO
❑INDIO AMERICANO/NATIVO DE ALASKA&NEGRO/AFRICANO AMERICANO
c. ETNICIDAD d.DISCAPACITADO e.ZES EL SOLICITANTE UNA MWER Y CABECERA DEL HOGAR?
❑HISPANO ❑ SI ❑ SI
❑NO-HISPANO ❑NO ❑NO
*NUMERO TOTAL DE MIEMBROS EN EL HOGAR (Incluye a si mismo y a todos los que viven en la casa)
Ingreso total del hogar anual anticipado:
Certificaci6n:
Certifico que la informacion que proporciono es verdad y podria ser susceptible a la comprobaci6n a cualquier
tiempo por terceros. Yo tambien reconozco que la provision de informacion falsa me podria dejar sujeto a las
penalidades Federales, Estatales y locales.
ADVERTENCIA: TITULO 18,SECCI6N 1001 DEL CODIGO DE EE.UU. QUE UNA PERSONA ES CULPABLE DE
UN DELITO POR SABER Y VOLUNTARIAMENTE RACER DECLARACIONES FALSAS O FRAUDULENTAS A
CUALQUIER DEPARTAMENTO DEL GOBIERNO ESTADOUNIDENSE.
Firma del Solicitante Fecha
----------------- ara use de em leados de la a encia-----------------
#De Miembros de Familia: Ingreso Anual:
Limite de Ingreso: �Es solicitante elegible?
Compruebe si el solicitante se nego a dar su informacion personal: ❑
Evaluaci6n del empleado sobre informacion personal:
Persona haciendo la determinaci6n: Fecha:
Note: La direccidn de la casa y los ingresos (y sus origenes) para todos miembros del hogar son requeridos.
HOPWA CONTRACT 2015-2016--EXHIBIT"E"--INCOME CERTIFICATION FORMS Page 3
Tarrant County Samaritan Housing,Inc.
EXHIBIT "F"
STANDARDS OF DOCUMENTATION
HOPWA PSA CONTRACT 2015-2016--EXHIBIT"F"--STANDARDS OF DOCUMENTATION Page 1
Tarrant County Samaritan Housing,Inc.
2015-2016 Documentation Standards for
HOPWA Public Service Contract Expenses
Notes/Other
Em io ee Salaries,and:Bene,tts-.Gi "wtii reimburse the"saia and benefitspf an "e►it to ee s whowpk directs,.wttfi the„HOPWA P o ram ,Amounts wdl be;dete"rrftin"ed
r+or fo ttie execution oflhe,iiOPWA,Gontrac#:"A"ericies"must sfi�oyv caicuia#ton an how the FIOPWA";orkion"of em to eesaiartes an tienefts'were"C lculated constsferjti
W t the yOPWA"Contract"'The"aaiculatton(s)will"appiy"to the#10PWA Admmstratron line yitem,`;Sypportive Services;and"Facrirty Based Operations:
HOPWA-funded Program. For employees who are paid with multiple funding sources,timesheets must reflect all funding sources. If
separate timesheets are kept for each funding source,all such timesheets must be submitted to City. Timesheets must be signed by
employee and supervisor. Agency must show a calculation and documentation of how the employee's salary was calculated and invoiced
to City. For employees who are paid with multiple funding sources,timesheets must reflect all funding sources. If separate timesheets are
kept for each funding source,all such timesheets must be submitted to City. The duties for administrative personnel defined by the job
descriptions must reflect eligible administrative costs. Agencies will be required to identify hours worked on a specific activity,i.e.
Administrative,Supportive,or Operations.
Administrative Services:Employees who work hours for the general management,oversight,coordination,evaluation,and reporting of
HOPWA-eligible activities will be required to supply documentation reflecting hours worked on the HOPWA-funded Program. The duties
Salaries X X for administrative personnel defined by the job descriptions must reflect eligible administrative costs.
Supportive Services: Employees who work hours for direct client support,which includes but is not limited to housing case managment to
clients,assessing and monitor the client's needs and personal support systems,assisting clients with housing assesments,housing plans,
filling out intake forms,coordinating payment with hotels/motels,and provides referrals to other housing sources,etc.will be required to
supply documentation reflecting hours worked directly with clients.
Facility Based Operations: Employees who work hours for the daily and ongoing operation of a facility or facilities will be required to supply
documentation reflecting hours worked on the operation of a facility or facilities.
'If employees are paid by direct deposit rather than check,then the agency must submit both the direct deposit payment company's report
FICA/ X X
Medicare
Life Insurance X X
Health X X If the City pays gross salary,this is already included.If the City pays the employer portion,the Agency must provide proof that the
Insurance employee is enrolled in the benefit plan,must show a calculation and documentation of how the invoiced amount was calculated,and must
Disability X X provide documentation showing payment.
Insurance
Unemployment X X
Insurance
If the City pays gross salary,this is already included.If the City pays the employer portion,the Agency must provide proof that the
Retirement X X employee is enrolled in the benefit plan,must show a calculation and documentation of how the invoiced amount was calculated,and must
provide documentation showing payment.
Mnterrats E`uf"afent".G"oods`and"Su ties-:Ci" �riii onl"reimburse for#he'ainount s'ent on the.dlrect su "prt;of#he„"HOP"A fundet:Pro ram:A eiicies;re uestin
9." P... " ,a pP. tY. Y _:" P PP,." )�► .. 9„ 9.:.: 9 . . 9. ",>
reimbursementfor these rtems'will require error City approyai. Agencies inusYshpw calculation on how the klOP1NA portion of these expenses wgre caiculated'consjstgnfiy
with the liOPtl11A Contracts Costs":most be reasonable and documented expenses
Office Supplies X X X
Office
Equipment X X X X
Rental These costs can be associated with the delivery of a HOPWA activity provided by the Agency. Agencies will be required to identify which
expenses will be allocated to specific activities,i.e.Administrative,Supportive,or Operations.
Postage X X X
Printing/Copies X X X
Medical X X X
Supplies
Rent lrhlrt�es antl Maintena"rice',Ci "will",onl,.."a ":fora'rtirated-'oorton ofthese°eir"Qi�ses„The-;;prtibnvutll betletermined;b #he,s care"fciota a attriFiutabrefpthe.FiORUVA`
funded
_Wan shah be cost allocated m accordance wtth the amount of space used for tt�e HOPWA funded R rogram;,These expenses may only be rn support pf the;
HCPWA funded Pro ram The,fems h'sted below requ►re" `rror Ctty ap"royal qnd the A enc r required to ldentt an funding sourpe#hat pays for fhe portion of fhe
ez"'en es'f"at sntit:"'aid` ifh-Gi OPWAfu ds'-A a ciss sow ca cuatio»on"ho theHOPWA ortlonof# ese"ex"ensesu✓erecaieGlat
te
d-consrs "tl'wih the„`” "
�O�!UyAConfrac# = '�"
Telephone X X
Gas X X
Water/ X X
Wastewater
Electric X X
Solid Waste X X
Disposal
Facility This item requires approval by the City prior to the execution of the HOPWA Contract. Repairs may be categorized as major/minor
Maintenance X X X X rehabilitation projects and must be approved through the full HUD Environmetal Review.
and Repairs
Rent X X City will pay for a portion of the rent for the Program facility so long as its in proportion to the square footage attributable to the HOPWA-
funded program.
HOPWA PSA CONTRACT 2015-2016 Exhibit"F"—STANDARDS FOR COMPLETE DOCUMENTATION 1
Suppor#iue,Sery ices,STRIVIU/TBRA Client Eligibility Documentation
Demograhic Client documentation provided must reflect demographic&household/family composition.
Information
Medical Agency will submit information in the form of a letter that certifies that the Agency has medical documentation confirming the clients'
Documentation HIV/AIDS status.
STRMU Client X X X Agency will submit documentation that demonstrate compliance with the assistance time limits,21 weeks in any 52 week period,complete
lease,utility bill(s),proof of emergency situation,and income source documentation to show clients is at or below 80%AMI.
Agency will submit documentation that demonstrates the client was certified on an annual basis through an annual income certification or
TBRA Client X X X recertification,submit a complete lease,utility bill(s),Habitability Inspection or Housing Quality Standard(HQS)Inspection,Rent
Reasonableness,and income source documentation to show client is at or below 80%AMI.
City-required X X City will only pay for a percentage of the City-required insurance solong as it is in proportion to the square footage attributable to the
Insurance HOPWA-funded program.
City will only pay for a percentage of other required insurance. Insurance such as,but not limited to,Commercial Property and Liability,
Other Professional Liability,Crime and Fidelity,Business Auto,and Commercial Umbrella Liability,solong as it is in proportion to Agencies total
Insurance X X budget. Agencies will be required to identify which expenses will be allocated to specific activities,i.e.Administrative,Supportive,or
Operations. Agency must show a calculation and documentation of how the invoiced amount was calculated,and must provide
documentation showing payment.
This item requires prior approval by the City. Prior to the execution of the ESG Contract,the Agency must submit a written statement that
Procurement- lists the contract labor services to be used during the Contract term. Agency will submit a memo related to the procurement of such
Contract Labor X X X X X services and will forward any information pertaining to the procurement process to City. This requirement applies to,but is not limited to,
services retained for security services,legal,accounting,transportation providers,educational facilitators,nutritionist,hazmat services,
custodial services,etc. Agencies may not use the contract services of any City of Fort Worth Department.
If an audit is required because federal funds exceed$750,000,then the cost should be split evenly by all grant funding sources. Agency
Audit Services X X X X must show calculation on how the CDBG portion of the accounting services were calculated. For example,if the CDBG grant is 10%of
your Agency's budget,then invoice shall not exceed 10%of the overall cost. Agency must show a calculation and documentation of how
the invoiced amount was calculated,and must provide documentation showing payment.
HOPWA
CAPER Agency must submit a HOPWA CAPER quarterly report.
Quarterly
Report
*Proof of payment effective October 1,2013: Payments or Expenses must be documented in the following manner:
A)Image of the check AND bank statement showing the check cleared the bank;OR,
B)Image of the cancelled check(ex.At end of bank statement);OR,
C)Payroll Check Stub,"Advice",or Statement AND Bank Statement indicating payroll;OR,
D)For wire or e-transfers:Reciept or statement from payee/vendor OR bank statement.
Final as of 08 28 2015 Ihr
HOPWA PSA CONTRACT 2015-2016 Exhibit"F"--STANDARDS FOR COMPLETE DOCUMENTATION 1
EXHIBIT "G"
SECTION 3 REPORTING FORMS
HOPWA PSA CONTRACT 2015-2016--EXHIBIT"G"-- SECTION 3 REPORTING FORMS Page 1
Tarrant County Samaritan Housing,Inc.
EXHIBIT "G"
Section 3 Summary Report U.S.Department of Housing OMB Approval No: 2529-0043
Economic Opportunities for and Urban Development (exp. 11/30/2010)
Low—and Very Low-Income Persons Office of Fair Housing
And Equal Opportunity HUD Field Office:
Section back of page for Public Reporting Burden statement
1.Recipient Name&Address: (street,city,state,zip) 2.Federal Identification: (grant no.) 3. Total Amount of Award:
4.Contact Person 5.Phone: (Include area code)
6.Length of Grant: 7.Reporting Period:
8.Date Report Submitted: 9.Program Code: (Use separate sheet 10. Program Name:
for each program code)
Part I: Employment and Training Columns B,C and F are manda ory fields. Include New Hires in E&F
A B C D E F
Number of Number of New %of Aggregate Number %of Total Staff Hours Number of Section 3
Job Category New Hires Hires that are of Staff Hours of New Hires for Section 3 Employees Trainees
Sec.3 Residents that are Sec.3 Residents and Trainees
Professionals
Technicians
Office/Clerical
Construction by Trade(List)
Trade
Trade
Trade
Trade
Trade
Other List
Total
'Program Codes 3=Public/Indian Housing 4=Homeless Assistance 8=CDBG State Administered
1=Flexible Subsidy A=Development, 5=HOME 9=Other CD Programs
2=Section 2021811 B=Operation 6=HOME State Administered 10=Other Housing Programs
C=Modernization 7=CDBG Entitlement
Page 1 of 2 form HUD 60002(6/2001)
Ref 24 CFR 135
Part II: Contracts Awarded
1. Construction Contracts:
A. Total dollar amount of all contracts awarded on the project $
B. Total dollar amount of contracts awarded to Section 3 businesses $
C. Percentage of the total dollar amount that was awarded to Section 3 businesses %
D. Total number of Section 3 businesses receiving contracts
2. Non-Construction Contracts:
A. Total dollar amount all non-construction contracts awarded on the projectfactivity $
B. Total dollar amount of non-construction contracts awarded to Section 3 businesses $
C. Percentage of the total dollar amount that was awarded to Section 3 businesses %
D. Total number of Section 3 businesses receiving non-construction contracts
Part III: Summary
Indicate the efforts made to direct the employment and other economic opportunities generated by HUD financial assistance for housing
and community development programs,to the greatest extent feasible,toward low-and very low-income persons,particularly those who
are recipients of government assistance for housing. (Check all that apply.)
Attempted to recruit low-income residents through: local advertising media,signs prominently displayed at the project site,
contracts with the community organizations and public or private agencies operating within the metropolitan area(or
nonmetropolitan county)in which the Section 3 covered program or project is located,or similar methods.
Participated in a HUD program or other program which promotes the training or employment of Section 3 residents.
Participated in a HUD program or other program which promotes the award of contracts to business concerns which meet the
definition of Section 3 business concerns.
Coordinated with Youthbuild Programs administered in the metropolitan area in which the Section 3 covered project is located.
Other;describe below.
Public reporting for this collection of information is estimated to average 2 hours per response,including the time for reviewing instructions,
searching existing data sources,gathering and maintaining the data needed,and completing and reviewing the collection of information.
This agency may not collect this information,and you are not required to complete this form,unless it displays a currently valid OMB
number.
Section 3 of the Housing and Urban Development Act of 1968,as amended, 12 U.S.C. 1701 u,mandates that the Department ensures that
employment and other economic opportunities generated by its housing and community development assistance programs are directed
toward low-and very-low income persons,particularly those who are recipients of government assistance housing. The regulations are
found at 24 CFR Part 135. The information will be used by the Department to monitor program recipients'compliance with Section 3,to
assess the results of the Department's efforts to meet the statutory objectives of Section 3,to prepare reports to Congress,and by
recipients as self-monitoring tool. The data is entered into a database and will be analyzed and distributed. The collection of information
involves recipients receiving Federal financial assistance for housing and community development programs covered by Section 3. The
information will be collected annually to assist HUD in meeting its reporting requirements under Section 808(e)(6)of the Fair Housing Act
and Section 916 of the HCDA of 1992. An assurance of confidentiality is not applicable to this form. The Privacy Act of 1974 and OMB
Circular A-108 are not applicable. The reporting requirements do not contain sensitive questions. Data is cumulative;personal identifying
information is not included.
Page 2 of 2 form HUD 60002(11/2010)
Ref 24 CFR 135
Form HUD-60002,Section 3 Summary Report,Economic Opportunities for Low-and Very Low-Income Persons.
Instructions: This form is to be used to report annual 8. Program Code: Enter the appropriate program code as listed at
accomplishments regarding employment and other economic the bottom of the page.
opportunities provided to low-and very low-income persons under 9. Program Name: Enter the name of HUD Program corresponding
Section 3 of the Housing and Urban Development Act of 1968. The with the"Program Code"in number 8.
Section 3 regulations apply to any public and Indian housing
programs that receive: (1)development assistance pursuant to Part I: Employment and Training Opportunities
Section 5 of the U.S.Housing Act of 1937;(2)operating assistance Column A: Contains various job categories. Professionals are
pursuant to Section 9 of the U.S.Housing Act of 1937;or(3) defined as people who have special knowledge of an occupation(i.e.
modernization grants pursuant to Section 14 of the U.S.Housing Act supervisors,architects,surveyors,planners,and computer
of 1937 and to recipients of housing and community development programmers). For construction positions,list each trade and provide
assistance in excess of$200,000 expended for: (1)housing data in columns B through F for each trade where persons were
rehabilitation(including reduction and abatement of lead-based paint employed. The category of"Other"includes occupations such as
hazards);(2)housing construction;or(3)other public construction service workers.
projects;and to contracts and subcontracts in excess of$100,000 Column B: (Mandatory Field) Enter the number of new hires for
awarded in connection with the Section-3-covered activity. each category of workers identified in Column A in connection with
Form HUD-60002 has three parts,which are to be completed for this award. New hire refers to a person who is not on the contractor's
all programs covered by Section 3. Part I relates to employment or recipient's payroll for employment at the time of selection for the
and training.The recipient has the option to determine numerical Section 3 covered award or at the time of receipt of Section 3 covered
employment/training goals either on the basis of the number of hours assistance.
worked by new hires(columns B,D,E and F). Part ll of the form Column C: (Mandatory Field) Enter the number of Section 3 new
relates to contracting,and Part III summarizes recipients'efforts to hires for each category of workers identified in Column A in
comply with Section 3. connection with this award. Section 3 new hire refers to a Section 3
Recipients or contractors subject to Section 3 requirements must resident who is not on the contractor's or recipient's payroll for
maintain appropriate documentation to establish that HUD financial employment at the time of selection for the Section 3 covered award or
assistance for housing and community development programs were at the time of receipt of Section 3 covered assistance.
directed toward low-and very low-income persons.* A recipient of Column D: Enter the percentage of all the staff hours of new hires
Section 3 covered assistance shall submit one copy of this report to (Section 3 residents)in connection with this award.
HUD Headquarters,Office of Fair Housing and Equal Opportunity. Column E: Enter the percentage of the total staff hours worked for
Where the program providing assistance requires an annual Section 3 employees and trainees(including new hires)connected
performance report,this Section 3 report is to be submitted at the with this award. Include staff hours for part-time and full-time
same time the program performance report is submitted. Where an positions.
annual performance report is not required,this Section 3 report is to be Column F: (Mandatory Field) Enter the number of Section 3
submitted by January 10 and,if the project ends before December 31, residents that were trained in connection with this award.
within 10 days of project completion. Only Prime Recipients are Part II: Contract Opportunities
required to report to HUD. The report must include Block 1: Construction Contracts
accomplishments of all recipients and their Section 3 covered Item A: Enter the total dollar amount of all contracts awarded on the
contractors and subcontractors. project/program.
HUD Field Office: Enter the Field Office name. Item B: Enter the total dollar amount of contracts connected with this
1. Recipient: Enter the name and address of the recipient project/program that were awarded to Section 3 businesses.
submitting this report. Item C: Enter the percentage of the total dollar amount of contracts
2. Federal Identification: Enter the number that appears on the connected with this project/program awarded to Section 3 businesses.
award form(with dashes). The award may be a grant, Item D: Enter the number of Section 3 businesses receiving awards.
cooperative agreement or contract. Block 2: Non-Construction Contracts
3. Dollar Amount of Award: Enter the dollar amount,rounded to the Item A: Enter the total dollar amount of all contracts awarded on the
nearest dollar,received by the recipient. project/program.
4&5. Contact Person/Phone: Enter the name and telephone number Item B: Enter the total dollar amount of contracts connected with this
of the person with knowledge of the award and the recipient's project awarded to Section 3 businesses.
implementation of Section 3. Item C: Enter the percentage of the total dollar amount of contracts
6. Reporting Period: Indicate the time period(months and year) connected with this project/program awarded to Section 3 businesses.
this report covers. Item D: Enter the number of Section 3 businesses receiving awards.
7. Date Report Submitted: Enter the appropriate date. Part III: Summary of Efforts—Self-explanatory
Submit one(1)copy of this report to the HUD Headquarters Office of
Fair Housing and Equal Opportunity,at the same time the The Secretary may establish income ceilings higher or lower than 80 percent
performance report is submitted to the program office. The Section 3 of the median for the area on the basis of the Secretary's findings such that
report is submitted by January 10. Include only contracts executed variations are necessary because of prevailing levels of construction costs
during the period specified in item 8. PHAs/IHAs are to report all or unusually high-or low-income families. Very low-income persons mean
contracts/subcontracts. low-income families(including single persons)whose incomes do not
exceed 50 percent of the median family income area,as determined by the
* The terms"low-income persons"and very low-income persons"have Secretary with adjustments or smaller and larger families,except that the
the same meanings given the terms in section 3(b)(2)of the United Secretary may establish income ceilings higher or lower than 50 percent of
States Housing Act of 1937. Low-income persons mean families the median for the area on the basis of the Secretary's findings that such
(including single persons)whose incomes do not exceed 80 percent of variations are necessary because of unusually high or low family incomes.
the median income for the area,as determined by the Secretary,with
adjustments for smaller and larger families,except that
Page i form HUD 60002(11/2010)
Ref 24 CFR 135
EXHIBIT "H"
OVERVIEW REPORT
HOPWA PSA CONTRACT 2015-2016—EXHIBIT"H"—OVERVIEW REPORT Page 1
Tarrant County Samaritan Housing,Inc.
P,11IENT0,
Q
�eU!OEVF�O
Housing Opportunities for Persons with AIDS
(HOPWA) Program
Consolidated Annual Performance and
Evaluation Report (CAPER)
Measuring Performance Outcomes
Final Released 1/12/12
OMB Number 2506-0133(Expiration Date: 10131/2014)
The CAPER report for HOPWA formula grantees provides annual information on program accomplishments
that supports program evaluation and the ability to measure program beneficiary outcomes as related to:
maintain housing stability;prevent homelessness;and improve access to care and support. This information is
also covered under the Consolidated Plan Management Process(CPMP)report and includes Narrative
Responses and Performance Charts required under the Consolidated Planning regulations. The public reporting
burden for the collection of information is estimated to average 42 hours per manual response,or less if an
automated data collection and retrieval system is in use,along with 60 hours for record keeping,including the
time for reviewing instructions,searching existing data sources,gathering and maintaining the data needed, and
completing and reviewing the collection of information. Grantees are required to report on the activities
undertaken only,thus there may be components of these reporting requirements that may not be applicable. This
agency may not conduct or sponsor,and a person is not required to respond to a collection of information unless
that collection displays a valid OMB control number.
Previous editions are obsolete form HUD-40110-D(Expiration Date:10/31/2014)
Overview. The Consolidated Annual Performance and Evaluation Report Domestic Violence,Date of Contact,Date of Engagement,Financial
(CAPER)provides annual performance reporting on client outputs and Assistance,Housing Relocation&Stabilization Services,Employment,
outcomes that enables an assessment of grantee performance in achieving the Education,General Health Status,,Pregnancy Status,Reasons for Leaving,
housing stability outcome measure. The CAPER,in conjunction with the Veteran's Information,and Children's Education. Other HOPWA projects
Integrated Disbursement Information System(IDIS),fulfills statutory and sponsors may also benefit from collecting these data elements.
regulatory program reporting requirements and provides the grantee and
HUD with the necessary information to assess the overall program Final Assembly of Report. After the entire report is assembled,please
performance and accomplishments against planned goals and objectives. number each page sequentially.
HOPWA formula grantees are required to submit a CAPER,and complete
annual performance information for all activities undertaken during each Filing Requirements. Within 90 days of the completion of each program
program year in the IDIS,demonstrating coordination with other year,grantees must submit their completed CAPER to the CPD Director in
Consolidated Plan resources. HUD uses the CAPER and IDIS data to obtain the grantee's State or Local HUD Field Office,and to the HOPWA Program
essential information on grant activities,project sponsors,Subrecipient Office:at HOPWA@,hnd.gov. Electronic submission to HOPWA Program
organizations,housing sites,units and households,and beneficiaries(which office is preferred;however,if electronic submission is not possible,hard
includes racial and ethnic data on program participants). The Consolidated copies can be mailed to:Office of HIV/AIDS Housing,Room 7212,U.S.
Plan Management Process tool(CPMP)provides an optional tool to integrate Department of Housing and Urban Development,451 Seventh Street,SW,
the reporting of HOPWA specific activities with other planning and reporting Washington,D.C.
on Consolidated Plan activities.
Record Keeping. Names and other individual information must be kept
Table of Contents confidential,as required by 24 CFR 574.440.However,HUD reserves the
right to review the information used to complete this report for grants
PART 1:Grantee Executive Summary management oversight purposes,except for recording any names and other
1.Grantee Information identifying information. In the case that HUD must review client level
2.Project Sponsor Information data,no client names or identifying information will be retained or
3.Administrative Subrecipient Information recorded. Information is reported in aggregate to HUD without
4.Program Subrecipient Information personal identification.Do not submit client or personal information in
5.Grantee Narrative and Performance Assessment data systems to HUD.
a.Grantee and Community Overview
b.Annual Performance under the Action Plan
c.Barriers or Trends Overview Definitions
d.Assessment of Unmet Housing Needs Adjustment for Duplication: Enables the calculation of unduplicated
PART 2:Sources of Leveraging and Program Income output totals by accounting for the total number of households or units that
1. Sources of Leveraging received more than one type of HOPWA assistance in a given service
2. Program Income and Resident Rent Payments category such as HOPWA Subsidy Assistance or Supportive Services.For
PART 3:Accomplishment Data:Planned Goals and Actual Outputs example,if a client household received both TBRA and STRMU during the
PART 4:Summary of Performance Outcomes operating year,report that household in the category of HOPWA Housing
1.Housing Stability: Permanent Housing and Related Facilities Subsidy Assistance in Part 3,Chart 1,Column[lb]in the following manner:
2.Prevention of Homelessness: Short-Term Housing Payments
3.Access to Care and Support: Housing Subsidy Assistance with [11 Outputs'
Supportive Services HOPWA Housing Subsidy
PART 5:Worksheet-Determining Housing Stability Outcomes Number of
PART 6:Annual Certification of Continued Use for HOPWA Facility- Assistance Households
Based Stewardship Units(Only)
PART 7:Summary Overview of Grant Activities 1. Tenant-Based Rental Assistance I
A.Information on Individuals,Beneficiaries and Households Receiving Permanent Housing Facilities:
HOPWA Housing Subsidy Assistance(TBRA,STRMU,PHP,Facility 2a. Received Operating
Based Units,Master Leased Units ONLY) Subsidies/Leased units
B.Facility-Based Housing Assistance Transitional/Short-term Facilities:
2b. Received Operating Subsidies
Continued Use Periods. Grantees that received HOPWA funding for new
construction,acquisition,or substantial rehabilitations are required to operate
their facilities for HOPWA-eligible beneficiaries for a ten(10)years period. Permanent Housing Facilities:
If no further HOPWA funds are used to support the facility,in place of 3a Capital Development Projects placed
completing Section 713 of the CAPER,the grantee must submit an Annual in service during the operating year
Certification of Continued Project Operation throughout the required use
periods. This certification is included in Part 6 in CAPER.The required use
period is three(3)years if the rehabilitation is non-substantial. Transitional/Short-term Facilities:
3b. Capital Development Projects placed
In connection with the development of the Department's standards for in service during the operating year
Homeless Management Information Systems(HMIS),universal data
elements are being collected for clients of HOPWA-funded homeless Short-term Rent,Mortgage,and
assistance projects. These project sponsor/subrecipient records would 4. Utility Assistance 1
include:Name,Social Security Number,Date of Birth,Ethnicity and Race, Adjustment for duplication
Gender,Veteran Status,Disabling Conditions,Residence Prior to Program 5 (subtract)1
Entry,Zip Code of Last Permanent Address,Housing Status,Program Entry
Date,Program Exit Date,Personal Identification Number,and Household TOTAL Housing Subsidy
Identification Number. These are intended to match the elements under 6. Assistance(Sum of Rows 1-4 minus 1
HMIS.The HOPWA program-level data elements include:Income and Row 5
Sources,Non-Cash Benefits,HIV/AIDS Status,Services Provided,and
Housing Status or Destination at the end of the operating year. Other
suggested but optional elements are:Physical Disability,Developmental
Disability,Chronic Health Condition,Mental Health,Substance Abuse,
Previous editions are obsolete Page i form HUD-40110-D(Expiration Date:10/31/2014)
Administrative Costs: Costs for general management,oversight, employees. Local affiliates of national organizations are not considered
coordination,evaluation,and reporting. By statute,grantee administrative "grassroots."
costs are limited to 3%of total grant award,to be expended over the life of
the grant. Project sponsor administrative costs are limited to 7%of the HOPWA Eligible Individual: The one(1)low-income person with
portion of the grant amount they receive. HIV/AIDS who qualifies a household for HOPWA assistance.This person
may be considered"Head of Household."When the CAPER asks for
Beneficiary(ies):All members of a household who received HOPWA information on eligible individuals,report on this individual person only.
assistance during the operating year including the one individual who Where there is more than one person with HIV/AIDS in the household,the
qualified the household for HOPWA assistance as well as any other additional PWH/A(s),would be considered a beneficiary(s).
members of the household(with or without HIV)who benefitted from the
assistance. HOPWA Housing Information Services: Services dedicated to helping
persons living with HIV/AIDS and their families to identify,locate,and
Central Contractor Registration(CCR): The primary registrant acquire housing.This may also include fair housing counseling for eligible
database for the U.S.Federal Government.CCR collects,validates,stores, persons who may encounter discrimination based on race,color,religion,
and disseminates data in support of agency acquisition missions,including sex,age,national origin,familial status,or handicap/disability.
Federal agency contract and assistance awards.Both current and potential
federal government registrants(grantees)are required to register in CCR HOPWA Housing Subsidy Assistance Total: The unduplicated number
in order to be awarded contracts by the federal government.Registrants of households receiving housing subsidies(TBRA,STRMU,Permanent
must update or renew their registration at least once per year to maintain Housing Placement services and Master Leasing)and/or residing in units
an active status.Although recipients of direct federal contracts and grant of facilities dedicated to persons living with HIV/AIDS and their families
awards have been required to be registered with CCR since 2003,this and supported with HOPWA funds during the operating year.
requirement is now being extended to indirect recipients of federal funds
with the passage of ARRA(American Recovery and Reinvestment Act). Household: A single individual or a family composed of two or more
Per ARRA and FFATA(Federal Funding Accountability and persons for which household incomes are used to determine eligibility and
Transparency Act)federal regulations,all grantees and sub-grantees or for calculation of the resident rent payment. The term is used for
subcontractors receiving federal grant awards or contracts must have a collecting data on changes in income,changes in access to services,receipt
DUNS(Data Universal Numbering System)Number. of housing information services,and outcomes on achieving housing
stability.Live-In Aides(see definition for Live-In Aide)and non-
Chronically Homeless Person:An individual or family who:(i)is beneficiaries(e.g.a shared housing arrangement with a roommate)who
homeless and lives or resides individual or family who:(i)Is homeless and resided in the unit are not reported on in the CAPER.
lives or resides in a place not meant for human habitation,a safe haven,or
in an emergency shelter;(ii)has been homeless and living or residing in a Housing Stability: The degree to which the HOPWA project assisted
place not meant for human habitation,a safe haven,or in an emergency beneficiaries to remain in stable housing during the operating year. See
shelter continuously for at least 1 year or on at least 4 separate occasions in Part 5:Determining Housing Stability Outcomes for definitions of stable
the last 3 years;and(iii)has an adult head of household(or a minor head and unstable housing situations.
of household if no adult is present in the household)with a diagnosable
substance use disorder,serious mental illness,developmental disability(as In-kind Leveraged Resources: These involve additional types of support
defined in section 102 of the Developmental Disabilities Assistance and provided to assist HOPWA beneficiaries such as volunteer services,
Bill of Rights Act of 2000(42 U.S.C. 15002)),post traumatic stress materials,use of equipment and building space. The actual value of the
disorder,cognitive impairments resulting from a brain injury,or chronic support can be the contribution of professional services,based on
physical illness or disability,including the co-occurrence of 2 or more of customary rates for this specialized support,or actual costs contributed
those conditions.Additionally,the statutory definition includes as from other leveraged resources. In determining a rate for the contribution
chronically homeless a person who currently lives or resides in an of volunteer time and services,use the rate established in HUD notices,
institutional care facility,including a jail,substance abuse or mental health such as the rate of ten dollars per hour. The value of any donated material,
treatment facility,hospital or other similar facility,and has resided there equipment,building,or lease should be based on the fair market value at
for fewer than 90 days if such person met the other criteria for homeless time of donation. Related documentation can be from recent bills of sales,
prior to entering that facility.(See 42 U.S.C. 11360(2))This does not advertised prices,appraisals,or other information for comparable property
include doubled-up or overcrowding situations. similarly situated.
Disabling Condition: Evidencing a diagnosable substance use disorder,
serious mental illness,developmental disability,chronic physical illness, Leveraged Funds: The amount of funds expended during the operating
or disability,including the co-occurrence of two or more of these year from non-HOPWA federal,state,local,and private sources by
conditions. In addition,a disabling condition may limit an individual's grantees or sponsors in dedicating assistance to this client population.
ability to work or perform one or more activities of daily living.An Leveraged funds or other assistance are used directly in or in support of
HIV/AIDS diagnosis is considered a disabling condition. HOPWA program delivery.
Facility-Based Housing Assistance: All eligible HOPWA Housing Live-In Aide: A person who resides with the HOPWA Eligible Individual
expenditures for or associated with supporting facilities including and who meets the following criteria: (1)is essential to the care and well-
community residences,SRO dwellings,short-term facilities,project-based
rental units,master leased units,and other housing facilities approved by being of the person;(2)is not obligated for the support of the person;and
HUD. (3)would not be living in the unit except to provide the necessary
supportive services. See the Code of Federal Regulations Title 24,Part
Faith-Based Organization: Religious organizations of three types:(1) 5.403 and the HOPWA Grantee Oversight Resource Guide for additional
congregations;(2)national networks,which include national reference.
denominations,their social service arms(for example,Catholic Charities,
Lutheran Social Services),and networks of related organizations(such as Master Leasing:Applies to a nonprofit or public agency that leases units
YMCA and YWCA);and(3)freestanding religious organizations,which of housing(scattered-sites or entire buildings)from a landlord,and
are incorporated separately from congregations and national networks. subleases the units to homeless or low-income tenants.By assuming the
tenancy burden,the agency facilitates housing of clients who may not be
Grassroots Organization: An organization headquartered in the local able to maintain a lease on their own due to poor credit,evictions,or lack
community where it provides services;has a social services budget of of sufficient income.
$300,000 or less annually,and six or fewer full-time equivalent
Previous editions are obsolete Page ii form HUD-40110-D(Expiration Date:10/31/2014)
Subrecipient Organization: Any organization that receives funds from a
Operating Costs: Applies to facility-based housing only,for facilities project sponsor to provide eligible housing and other support services
that are currently open. Operating costs can include day-to-day housing and/or administrative services as defined in 24 CFR 574.300. If a
function and operation costs like utilities,maintenance,equipment, subrecipient organization provides housing and/or other supportive
insurance,security,furnishings,supplies and salary for staff costs directly services directly to clients,the subrecipient organization must provide
related to the housing project but not staff costs for delivering services. performance data on household served and funds expended. Funding
flows to subrecipients as follows:
Outcome: The degree to which the HOPWA assisted household has been
enabled to establish or maintain a stable living environment in housing that HUD Funding ---->Grantee -->Project Sponsor>Subrecipient
is safe,decent,and sanitary,(per the regulations at 24 CFR 574.310(b))
and to reduce the risks of homelessness,and improve access to HIV Tenant-Based Rental Assistance(TBRA): TBRA is a rental subsidy
treatment and other health care and support. program similar to the Housing Choice Voucher program that grantees can
provide to help low-income households access affordable housing. The
Output: The number of units of housing or households that receive TBRA voucher is not tied to a specific unit,so tenants may move to a
HOPWA assistance during the operating year. different unit without losing their assistance,subject to individual program
rules. The subsidy amount is determined in part based on household
Permanent Housing Placement: A supportive housing service that helps income and rental costs associated with the tenant's lease.
establish the household in the housing unit,including but not limited to
reasonable costs for security deposits not to exceed two months of rent Transgender: Transgender is defined as a person who identifies with,or
costs. presents as,a gender that is different from his/her gender at birth.
Program Income: Gross income directly generated from the use of Veteran: A veteran is someone who has served on active duty in the
HOPWA funds,including repayments. See grant administration Armed Forces of the United States. This does not include inactive military
requirements on program income for state and local governments at 24 reserves or the National Guard unless the person was called up to active
CFR 85.25,or for non-profits at 24 CFR 84.24. duty.
Project-Based Rental Assistance(PBRA): A rental subsidy program
that is tied to specific facilities or units owned or controlled by a project
sponsor or Subrecipient. Assistance is tied directly to the properties and is
not portable or transferable.
Project Sponsor Organizations: Any nonprofit organization or
governmental housing agency that receives funds under a contract with the
grantee to provide eligible housing and other support services or
administrative services as defined in 24 CFR 574.300. Project Sponsor
organizations are required to provide performance data on households
served and funds expended. Funding flows to a project sponsor as
follows:
HUD Funding - Grantee-->Project Sponsor
Short-Term Rent,Mortgage,and Utility(STRMIJ)Assistance: A
time-limited,housing subsidy assistance designed to prevent homelessness
and increase housing stability. Grantees may provide assistance for up to
21 weeks in any 52 week period. The amount of assistance varies per
client depending on funds available,tenant need and program guidelines.
Stewardship Units: Units developed with HOPWA,where HOPWA
funds were used for acquisition,new construction and rehabilitation that
no longer receive operating subsidies from HOPWA. Report information
for the units is subject to the three-year use agreement if rehabilitation is
non-substantial and to the ten-year use agreement if rehabilitation is
substantial.
Previous editions are obsolete Page iii form HUD-40110-D(Expiration Date:10/31/2014)
Housing Opportunities for Person with AIDS (HOPWA)
Consolidated Annual Performance and Evaluation Report (CAPER)
Measuring Performance Outputs and Outcomes
OMB Number 2506-0133(Expiration Date: 10/31/2014)
Part 1: Grantee Executive Summary
As applicable,complete the charts below to provide more detailed information about the agencies and organizations responsible
for the administration and implementation of the HOPWA program. Chart 1 requests general Grantee Information and Chart 2 is
to be completed for each organization selected or designated as a project sponsor,as defined by CFR 574.3. In Chart 3, indicate
each subrecipient organization with a contract/agreement of$25,000 or greater that assists grantees or project sponsors carrying
out their administrative or evaluation activities. In Chart 4, indicate each subrecipient organization with a contractiagreement to
provide HOPWA-funded services to client households. These elements address requirements in the Federal Funding and
Accountability and Transparency Act of 2006(Public Law 109-282).
Note:Please see the definition section for distinctions between project sponsor and subrecipient.
Note:If any information does not apply to your organization,please enter N/A. Do not leave any section blank.
1.Grantee Information
HUD Grant Number Operating Year for this report
From(nun/dd/yy) To(miWdd/yy)
Grantee Name
Business Address
City,County,State,Zip
Employer Identification Number(EIN)or
Tax Identification Number(TIN)
DUN&Bradstreet Number(DUNS): Central Contractor Registration(CCR):
Is the grantee's CCR status currently active?
❑Yes ❑No
If yes,provide CCR Number:
*Congressional District of Grantee's Business
Address
*Congressional District of Primary Service
Area(s)
*City(ies)and County(ies)of Primary Service Cities: Counties:
Area(s)
Organization's Website Address Is there a waiting list(s)for HOPWA Housing Subsidy Assistance
Services in the Grantee service Area? ❑Yes ❑No
If yes,explain in the narrative section what services maintain a waiting
list and how this list is administered.
Service delivery area information only needed for program activities being directly carried out by the grantee.
Previous editions are obsolete Page 1 form HUD-40110-D(Expiration Date:10/31/2014)
2.Project Sponsor Information
Please complete Chart 2 for each organization designated or selected to serve as a project sponsor,as defined by CFR 574.3.
Use this section to report on organizations involved in the direct delivery of services for client households. These elements
address requirements in the Federal Financial Accountability and Transparency Act of 2006(Public Law 109-282).
Note:Please see the definitions for distinctions between project sponsor and subrecipient.
Note:If any information does not apply to your organization,please enter N/A.
Project Sponsor Agency Name Parent Company Name,if applicable
Name and Title of Contact at Project
Sponsor Agency
Email Address
Business Address
City,County,State,Zip,
Phone Number(with area code)
Employer Identification Number(EIN)or Fax Number(with area code)
Tax Identification Number(TIN)
DUN&Bradstreet Number(DUNS):
Congressional District of Project Sponsor's
Business Address
Congressional District(s)of Primary Service
Area(s)
City(ies)and County(ies)of Primary Service Cities: Counties:
Area(s)
Total HOPWA contract amount for this
Organization for the operating year
Organization's Website Address
Is the sponsor a nonprofit organization? E]Yes ❑No
Does your organization maintain a waiting list? ❑Yes ❑No
Please check ifyes and afaith-based organization. ❑ If yes,explain in the narrative section how this list is administered.
Please check if yes and a grassroots organization. ❑
Previous editions are obsolete Page 2 form HUD-40110-D(Expiration Date:10/31/2014)
3.Administrative Subrecipient Information
Use Chart 3 to provide the following information for each subrecipient with a contract/agreement of$25,000 or greater that
assists project sponsors to carry out their administrative services but no services directly to client households. Agreements
include:grants,subgrants,loans,awards,cooperative agreements,and other forms of financial assistance;and contracts,
subcontracts,purchase orders,task orders,and delivery orders. (Organizations listed may have contracts with project sponsors)
These elements address requirements in the Federal Funding and Accountability and Transparency Act of 2006(Public Law 109-
282).
Note:Please see the definitions for distinctions between project sponsor and subrecipient.
Note:If any information does not apply to your organization,please enter N/A.
Subrecipient Name Parent Company Name,if applicable
Name and Title of Contact at Subrecipient
Email Address
Business Address
City,State,Zip,County
Phone Number(with area code) Fax Number(include area code)
Employer Identification Number(EIN)or
Tax Identification Number(TIN)
DUN&Bradstreet Number(DUNS):
North American Industry Classification
System AICS)Code
Congressional District of Subrecipient's
Business Address
Congressional District of Primary Service
Area
City(ies)and County(ies)of Primary Service Cities: Counties:
Area(s)
Total HOPWA Subcontract Amount of this
Organization for the operating ear
Previous editions are obsolete Page 3 form HUD-40110-D(Expiration Date:10/31/2014)
4.Program Subrecipient Information
Complete the following information for each subrecipient organization providing HOPWA-funded services to client households.
These organizations would hold a contract/agreement with a project sponsor(s)to provide these services. For example,a
subrecipient organization may receive funds from a project sponsor to provide nutritional services for clients residing within a
HOPWA facility-based housing program.Please note that subrecipients who work directly with client households must provide
performance data for the grantee to include in Parts 2-7 of the CAPER.
Note:Please see the definition of a subrecipient for more information.
Note: Types of contracts/agreements may include:grants, sub-grants, loans, awards, cooperative agreements, and other forms
offinancial assistance; and contracts, subcontracts,purchase orders, task orders, and delivery orders.
Note:If any information is not applicable to the organization,please report N/A in the appropriate box. Do not leave boxes
blank.
Sub-recipient Name Parent Company Name,if applicable
Name and Title of Contact at Contractor/
Sub-contractor Agency
Email Address
Business Address
City,County,State,Zip
Fax Number(include area code)
Phone Number(included area code)
Employer Identification Number(EIN)or
Tax Identification Number(TIN)
DUN&Bradstreet Number(DUNS)
North American Industry Classification
System(NAICS)Code
Congressional District of the Sub-recipient's
Business Address
Congressional District(s)of Primary Service
Area
City(ies)and County(ies)of Primary Service Counties:
Area Cities:
Total HOPWA Subcontract Amount of this
Organization for the operating year
Previous editions are obsolete Page 4 form HUD-40110-D(Expiration Date:10/31/2014)
5.Grantee Narrative and Performance Assessment
a.Grantee and Community Overview
Provide a one to three page narrative summarizing major achievements and highlights that were proposed and completed during
the program year. Include a brief description of the grant organization,area of service,the name(s)of the program contact(s),
and an overview of the range/type of housing activities provided. This overview may be used for public information,including
posting on HUD's website. Note: Text fields are expandable.
b.Annual Performance under the Action Plan
Provide a narrative addressing each of the following four items:
1. Outputs Reported. Describe significant accomplishments or challenges in achieving the number of housing units supported
and the number households assisted with HOPWA funds during this operating year compared to plans for this assistance,as
approved in the Consolidated Plan/Action Plan. Describe how HOPWA funds were distributed during your program year among
different categories of housing and geographic areas to address needs throughout the grant service area,consistent with approved
plans.
2. Outcomes Assessed. Assess your program's success in enabling HOPWA beneficiaries to establish and/or better maintain a
stable living environment in housing that is safe,decent,and sanitary,and improve access to care. Compare current year results
to baseline results for clients. Describe how program activities/projects contributed to meeting stated goals. If program did not
achieve expected targets,please describe how your program plans to address challenges in program implementation and the steps
currently being taken to achieve goals in next operating year. If your program exceeded program targets,please describe
strategies the program utilized and how those contributed to program successes.
3. Coordination. Report on program coordination with other mainstream housing and supportive services resources, including
the use of committed leveraging from other public and private sources that helped to address needs for eligible persons identified
in the Consolidated Plan/Strategic Plan.
4.Technical Assistance. Describe any program technical assistance needs and how they would benefit program beneficiaries.
c. Barriers and Trends Overview
Provide a narrative addressing items 1 through 3.Explain how barriers and trends affected your program's ability to achieve the
objectives and outcomes discussed in the previous section.
1.Describe any barriers(including regulatory and non-regulatory)encountered in the administration or implementation of
the HOPWA program,how they affected your program's ability to achieve the objectives and outcomes discussed,and,
actions taken in response to barriers,and recommendations for program improvement.Provide an explanation for each
❑HOPWA/HUD Regulations ❑Planning ❑Housing Availability ❑Rent Determination and Fair Market
Rents
❑Discrimination/Confidentiality ❑Multiple Diagnoses ❑Eligibility ❑Technical Assistance or Training
barrier selected.
Previous editions are obsolete Page 5 form HUD-40110-D(Expiration Date:10/31/2014)
❑Supportive Services ❑Credit History ❑Rental History
❑Criminal Justice History
❑Housing Affordability
❑Geography/Rural Access ❑Other,please explain further
2. Describe any trends in the community that may affect the way in which the needs of persons living with HIV/AIDS
are being addressed, and provide any other information important to the future provision of services to this population.
3. Identify any evaluations,studies,or other assessments of the HOPWA program that are available to the public.
d.Unmet Housing Needs: An Assessment of Unmet Housing Needs
In Chart 1,provide an assessment of the number of HOPWA-eligible households that require HOPWA housing subsidy
assistance but are not currently served by any HOPWA-funded housing subsidy assistance in this service area.
In Row 1,report the total unmet need of the geographical service area,as reported in Unmet Needs for Persons with HIV/AIDS,
Chart 1B of the Consolidated or Annual Plan(s),or as reported under HOPWA worksheet in the Needs Workbook of the
Consolidated Planning Management Process(CPMP)tool.
Note:Report most current data available, through Consolidated or Annual Plan(s), and account for local housing issues, or
changes in HIV/AIDS cases, by using combination of one or more of the sources in Chart 2.
If data is collected on the type of housing that is needed in Rows a.through c., enter the number of HOPWA-eligible households
by type of housing subsidy assistance needed. For an approximate breakdown of overall unmet need by type of housing subsidy
assistance refer to the Consolidated or Annual Plan(s),CPMP tool or local distribution of funds. Do not include clients who are
already receiving HOPWA-funded housing subsidy assistance.
Refer to Chart 2,and check all sources consulted to calculate unmet need. Reference any data from neighboring states' or
municipalities' Consolidated Plan or other planning efforts that informed the assessment of Unmet Need in your service area.
Note: In order to ensure that the unmet need assessment for the region is comprehensive, HOP WA formula grantees should
include those unmet needs assessed by HOPWA competitive grantees operating within the service area.
1. Planning Estimate of Area's Unmet Needs for HOPWA-Eligible Households
1. Total number of households that have unmet
housing subsidy assistance need.
Previous editions are obsolete Page 6 form HUD-40110-D(Expiration Date:10/31/2014)
2. From the total reported in Row 1, identify the
number of households with unmet housing needs
by type of housing subsidy assistance:
a.Tenant-Based Rental Assistance(TBRA)
b.Short-Term Rent,Mortgage and Utility payments
(STRMU)
• Assistance with rental costs
• Assistance with mortgage payments
• Assistance with utility costs.
c.Housing Facilities,such as community residences,
SRO dwellings,other housing facilities
Previous editions are obsolete Page 7 form HUD-40110-D(Expiration Date:10/31/2014)
2.Recommended Data Sources for Assessing Unmet Need check all sources used
=Data as reported in the area Consolidated Plan,e.g.Table 1B,CPMP charts,and related narratives
=Data established by area HN/AIDS housing planning and coordination efforts,e.g.Continuum of Care
=Data from client information provided in Homeless Management Information Systems(HMIS)
=Data from project sponsors or housing providers,including waiting lists for assistance or other assessments on need including those
completed by HOPWA competitive grantees operating in the region.
=Data from prisons or jails on persons being discharged with HIV/AIDS,if mandatory testing is conducted
=Data from local Ryan White Planning Councils or reported in CARE Act Data Reports,e.g.number of clients with permanent
housing
=Data collected for HIV/AIDS surveillance reporting or other health assessments,e.g.local health department or CDC surveillance data
End of PART 1
Previous editions are obsolete Page 8 form HUD-40110-D(Expiration Date:10/31/2014)
PART 2: Sources of Leveraging and Program Income
1. Sources of Leveraging
Report the source(s)of cash or in-kind leveraged federal,state, local or private resources identified in the Consolidated or
Annual Plan and used in the delivery of the HOPWA program and the amount of leveraged dollars. In Column[1],identify the
type of leveraging. Some common sources of leveraged funds have been provided as a reference point. You may add Rows as
necessary to report all sources of leveraged funds. Include Resident Rent payments paid by clients directly to private landlords.
Do NOT include rents paid directly to a HOPWA program as this will be reported in the next section. In Column [2]report the
amount of leveraged funds expended during the operating year. Use Column[3]to provide some detail about the type of
leveraged contribution(e.g.,case management services or clothing donations). In Column [4],check the appropriate box to
indicate whether the leveraged contribution was a housing subsidy assistance or another form of support.
Note: Be sure to report on the number of households supported with these leveraged funds in Part 3, Chart 1, Column d.
A. Source of Leveraging Chart
[2] Amount
of Leveraged [3] Type of [4] Housing Subsidy
[1] Source of Leveraging Funds Contribution Assistance or Other Support
Public Funding
❑Housing Subsidy Assistance
Ryan White-Housing Assistance ❑Other Support
❑Housing Subsidy Assistance
Ryan White-Other ❑Other Support
❑Housing Subsidy Assistance
Housing Choice Voucher Program ❑Other Support
❑Housing Subsidy Assistance
Low Income Housing Tax Credit ❑Other Support
❑Housing Subsidy Assistance
HOME port
❑Housing Subsidy Assistance
Shelter Plus Care ❑Other Support
❑Housing Subsidy Assistance
Emergency Solutions Grant ❑Other Su port
❑Housing Subsidy Assistance
Other Public: ❑Other Su port
❑Housing Subsidy Assistance
Other Public: port
❑Housing Subsidy Assistance
Other Public: ❑Other Support
❑Housing Subsidy Assistance
Other Public: port
❑Housing Subsidy Assistance
Other Public: ❑Other Support
Private Funding
❑Housing Subsidy Assistance
Grants ❑Other Support
❑Housing Subsidy Assistance
In-kind Resources ❑Other Su ort
❑Housing Subsidy Assistance
Other Private: ❑Other Support
❑Housing Subsidy Assistance
Other Private: ❑Other Support
Other Funding
❑Housing Subsidy Assistance
Grantee/Project S onsor/Subreci ient(Agency)Cash ❑Other Support
Resident Rent Payments by Client to Private Landlord
TOTAL Sum of all Rows
Previous editions are obsolete Page 9 form HUD-40110-D(Expiration Date:10/31/2014)
2. Program Income and Resident Rent Payments
In Section 2,Chart A.,report the total amount of program income and resident rent payments directly generated from the use of
HOPWA funds,including repayments. Include resident rent payments collected or paid directly to the HOPWA program. Do
NOT include payments made directly from a client household to a private landlord.
Note:Please see report directions section for definition of program income. (Additional information on program income is
available in the HOPWA Grantee Oversight Resource Guide).
A. Total Amount Program Income and Resident Rent Payment Collected During the Operating Year
Total Amount of
Program Income
Program Income and Resident Rent Payments Collected (for this operating
year)
1. Program income(e.g.repayments)
2. Resident Rent Payments made directly to HOPWA Program
. Total Program Income and Resident Rent Payments(Sum of Rows 1 and 2)
B. Program Income and Resident Rent Payments Expended To Assist HOPWA Households
In Chart B,report on the total program income and resident rent payments(as reported above in Chart A)expended during the
operating year. Use Row 1 to report Program Income and Resident Rent Payments expended on Housing Subsidy Assistance
Programs(i.e.,TBRA, STRMU,PHP,Master Leased Units,and Facility-Based Housing). Use Row 2 to report on the Program
Income and Resident Rent Payment expended on Supportive Services and other non-direct Housing Costs.
Total Amount of Program
Income Expended
Program Income and Resident Rent Payment Expended on (for this operating year)
HOPWA programs
1. Program Income and Resident Rent Payment Expended on Housing Subsidy Assistance costs
2. Program Income and Resident Rent Payment Expended on Supportive Services and other non-
direct housing costs
3. Total Program Income Expended(Sum of Rows 1 and 2)
End of PART 2
Previous editions are obsolete Page 10 form HUD-40110-D(Expiration Date:10/31/2014)
PART 3: Accomplishment Data Planned Goal and Actual Outputs
In Chart 1,enter performance information(goals and actual outputs)for all activities undertaken during the operating year
supported with HOPWA funds. Performance is measured by the number of households and units of housing that were supported
with HOPWA or other federal, state,local,or private funds for the purposes of providing housing assistance and support to
persons living with HIV/AIDS and their families.
Note: The total households assisted with HOPWA funds and reported in PART 3 of the CAPER should be the same as reported
in the annual year-end IDIS data, and goals reported should be consistent with the Annual Plan information. Any discrepancies
or deviations should be explained in the narrative section of PART 1.
1. HOPWA Performance Planned Goal and Actual Outputs
111 Output: Households 121 Output:Funding
HOPWA Leveraged
HOPWA Performance Assistance Households HOPWA Funds
Planned Goal a. b. c. d. C. f.
and Actual
a�
C'
OPWA Housing Subsidy Assistance 1 Output:Households 121 Outp'ut:Funding
1. Tenant-Based Rental Assistance
a. Permanent Housing Facilities:
Received Operating Subsidies/Leased units(Households Served)
b. Transitional/Short-term Facilities:
Received Operating Subsidies/Leased units(Households Served)
Households Served)
a. Permanent Housing Facilities:
Capital Development Projects placed in service during the operating year
Households Served)
b. Transitional/Short-term Facilities:
Capital Development Projects placed in service during the operating year
Households Served)
4. Short-Term Rent,Mortgage and Utility Assistance
5. Permanent Housing Placement Services
6. Adjustments for duplication(subtract)
7. 'Total HOPWA Housing Subsidy Assistance
(Columns a.—d. equal the sum of Rows 1-5 minus Row 6; Columns e.and f.equal
the sum of Rows 1-5
Housing Development(Construction and Stewardship of facility based housing)
III Output: Hous ng Units 121 Outp ut:Funding
8. Facility-based units;
Capital Development Projects not yet opened(Housing Units)
Stewardship Units subject to 3 or 10 year use agreements
10. Total Housing Developed
Sum of Rows 78&9
Supportive Services
1 I output [21 Out ut:Funding
I la.Supportive Services provided by project sponsors/subrecipient that also delivered
HOPWA housing subsidy assistance
I lb Supportive Services provided by project sponsors/subrecipient that only provided
supportive services.
12. Adjustment for duplication(subtract)
13. Total Supportive Services
Columns a.—d.equal the sum of Rows 11 a.&b.minus Row 12;Columns e.and f.
—equal the sum of Rows 11a.&11b.
Housing Information Services Ill OutpulHouseholdi"'" 121 Output:Funding
14. Housing Information Services
15. 'Total Housing Information Services
Previous editions are obsolete Page 11 form HUD-40110-D(Expiration Date:10/31/2014)
Grant Administration and Other Activities [1]Output Households [2]Output:Funding
16. Resource Identification to establish,coordinate and develop housing assistance resources
17. Technical Assistance
if approved in grant agreement)
18. Grantee Administration
maximum 3%of total HOPWA grant)
19. Project Sponsor Administration
maximum 7%of portion of HOPWA grant awarded)
0. otal Grant Administration and Other Activities
not of Rows 16-19)
121 Outputs: HOPWA Funds
71Expended Expended
Budget r Actual
1. Total Expenditures for program year(Sum of Rows 7,10,13,15,and 20)
2.Listing of Supportive Services
Report on the households served and use of HOPWA funds for all supportive services. Do NOT report on supportive services
leveraged with non-HOPWA funds.
Data check:Total unduplicated households and expenditures reported in Row 17 equal totals reported in Part 3, Chart 1,Row 13.
Supportive Services [11 Output:Number of Households 121 Output:Amount of HOPWA Funds
Expended
1. Adult day care and personal assistance
2. Alcohol and drug abuse services
30 Case management
4. Child care and other child services
5. Education
6. Employment assistance and training
Health/medical/intensive care services,if approved
7. Note: Client records must conform with 24 CFR 574.310
8. Legal services
9. Life skills management(outside of case management)
10. Meals/nutritional services
11. Mental health services
12. Outreach
13. Transportation
Other Activity(if approved in grant agreement).
14. Specify:
Sub-Total Households receiving Supportive Services
15. Sum of Rows 1-14
16. Adjustment for Duplication subtract
TOTAL Unduplicated Households receiving
Supportive Services(Column[1]equals Row 15
17. minus Row 16;Column[21 equals sum of Rows 1-14
Previous editions are obsolete Page 12 form HUD-40110-D(Expiration Date:10/31/2014)
3. Short-Term Rent,Mortgage and Utility Assistance(STRMU)Summary
In Row a.,enter the total number of households served and the amount of HOPWA funds expended on Short-Term Rent,
Mortgage and Utility(STRMU)Assistance. In Row b.,enter the total number of STRMU-assisted households that received
assistance with mortgage costs only(no utility costs)and the amount expended assisting these households. In Row c.,enter the
total number of STRMU-assisted households that received assistance with both mortgage and utility costs and the amount
expended assisting these households. In Row d.,enter the total number of STRMU-assisted households that received assistance
with rental costs only(no utility costs)and the amount expended assisting these households. In Row e.,enter the total number of
STRMU-assisted households that received assistance with both rental and utility costs and the amount expended assisting these
households. In Row f.,enter the total number of STRMU-assisted households that received assistance with utility costs only(not
including rent or mortgage costs)and the amount expended assisting these households. In row g.,report the amount of STRMU
funds expended to support direct program costs such as program operation staff.
Data Check.The total households reported as served with STRMU in Row a., column[1]and the total amount of HOPWA funds reported as
expended in Row a., column[2]equals the household and expenditure total reported for STRMU in Part 3, Chart 1,Role 4, Columns b. and f.,
respectively.
Data Check:The total number of households reported in Column[1],Rows b., c., d., e., and f. equal the total number of STRMU households
reported in Column[]],Row a. The total amount reported as expended in Column[2],Rows b., c., d., e.,f., and g.equal the total amount of
STRMU expenditures reported in Column[2],Row a.
[1] Output: Number of [2] Output: Total
Housing Subsidy Assistance Categories(STRMU) Households Served HOPWA Funds Expended
on STRMU during
Operating Year
Total Short-term mortgage,rent and/or utility(STRMU)
a. assistance
Of the total STRMU reported on Row a,total who received
b• assistance with mortgage costs ONLY.
Of the total STRMU reported on Row a,total who received
C. assistance with mortgage and utility costs.
Of the total STRMU reported on Row a,total who received
d. assistance with rental costs ONLY.
Of the total STRMU reported on Row a,total who received
e• assistance with rental and utility costs.
Of the total STRMU reported on Row a•total who received
f assistance with utility costs ONLY.
Direct program delivery costs(e.g.,program operations staff
time)
g•
End of PART 3
Previous editions are obsolete Page 13 form HUD-40110-D(Expiration Date:10/31/2014)
Part 4 Summary of Performance Outcomes
In Column[1],report the total number of eligible households that received HOPWA housing subsidy assistance,by type.
In Column[2],enter the number of households that continued to access each type of housing subsidy assistance into next
operating year. In Column[3],report the housing status of all households that exited the program.
Data Check: The sum of Columns[2](Number of Households Continuing)and[3](Exited Households)equals the total reported in Column[I].
Note:Refer to the housing stability codes that appear in Part S: Worksheet-Determining Housing Stability Outcomes.
Section 1.Housing Stability:Assessment of Client Outcomes on Maintaining Housing Stability(Permanent Housing and
Related Facilities)
A.Permanent ousing Subsidy Assistance
Ill Output:Total [2]Assessment:Number of [3]Assessment:Number of
Number of Households that Continued Households that exited this 141 HOPWA Client
Households Receiving HOPWA Housing HOPWA Program;their Housing Outcomes
Served Subsidy Assistance into the Next Status after Exiting
Operating Year
1 Emergency Shelter/Streets Unstable Arrangements
2 Temporary Housing Temporarily Stable,with Reduced
Risk of Homelessness
3 Private Housing
Tenant-Based
Rental 4 Other HOPWA
Assistance Stable/Permanent Housing(PH)
5 Other Subsidy
6 Institution
7 Jail/Prison
Unstable Arrangements
8 Disconnected/Unknown
9 Death Life Event
1 Emergency Shelter/Streets Unstable Arrangements
2 Temporary Housing Temporarily Stable,with Reduced
Risk of Homelessness
3 Private Housing
Permanent
Supportive 4 Other HOPWA
Housing Stable/Permanent Housing(PH)
g 5 Other Subsidy
Facilities/Units
6 Institution
7 fail/Prison
8 Disconnected/Unknown Unstable Arrangements
9 Death j Life Event
B.Transitional Housing Assistance
[1]Output: Total [21 Assessment:Number of [3]Assessment:Number of
Number of Households that Continued Households that exited this
Households Receiving HOPWA Housing HOPWA Program;their [41 HOPWA Client Outcomes
Served Subsidy Assistance into the Next Housing Status after Exiting
Operating Year
i Emergency Shelter/Streets Unstable Arrangements
2 Temporary Housing Temporarily Stable with Reduced
Risk of Homelessness
Transitional/ 3 Private Housing
Short-Term
Housing 4 Other HOPWA
Facilities/Units 5 Other Subsidy Stable/Permanent Housing(PH)
6 Institution
7 Jail/Prison
Unstable Arrangements
8 Disconnected/unknown
9 Death Life Event
Previous editions are obsolete Page 14 form HUD-40110-D(Expiration Date:10/31/2014)
B!:Total number of households receiving transitional/short-term housing
assistance whose tenure exceeded 24 months
Section 2.Prevention of Homelessness: Assessment of Client Outcomes on Reduced Risks of Homelessness
(Short-Term Housing Subsidy Assistance)
Report the total number of households that received STRMU assistance in Column [1].
In Column[2],identify the outcomes of the households reported in Column[1]either at the time that they were known to have
left the STRMU program or through the project sponsor or subrecipient's best assessment for stability at the end of the operating
year.
Information in Column[3]provides a description of housing outcomes;therefore,data is not required.
At the bottom of the chart:
• In Row Ia.,report those households that received STRMIJ assistance during the operating year of this report, and the
prior operating year.
• In Row 1 b.,report those households that received STRMU assistance during the operating year of this report,and the
two prior operating years.
Data Check: The total households reported as served with STRMU in Column[1]equals the total reported in Part 3, Chart 1,
Row 4, Column b.
Data Check: The sum of Column[21 should equal the number of households reported in Column[1].
Assessment of Households that Received STRMU Assistance
[1] Output: Total [2]Assessment of Housing Status [3]HOPWA Client Outcomes
number of
households
Maintain Private Housing without subsidy
(e.g.Assistance provided/conipleted and client is stable,not
likely to seek additional support)
Other Private Housing without subsidy
(e.g.client switched housing units and is now stable,not likely
to seek additional support)
Stable/Permanent Housing(PH)
Other HOPWA Housing Subsidy Assistance
Other Housing Subsidy(PH)
Institution
(e.g.residential and long-term care)
Likely that additional STRMU is needed to maintain current
housing arrangements
Transitional Facilities/Short-term Temporarily Stable, with
(e.g.temporary or transitional arrangement) Reduced Risk of Homelessness
Temporary/Non-Permanent Housing arrangement
(e.g.gave up lease,and moved in with family or f lends but
expects to live there less than 90 days)
Emergency Shelter/street
Jail/Prison Unstable Arrangements
Disconnected
Death Life Event
1 a.Total number of those households that received STRMU Assistance in the operating year of this report that also received
STRMU assistance in the prior operating year(e.g.households that received STRMU assistance in two consecutive operating
years).
lb.Total number of those households that received STRMU Assistance in the operating year of this report that also received
STRMU assistance in the two prior operating years(e.g.households that received STRMU assistance in three consecutive
operating years).
Previous editions are obsolete Page 15 form HUD-40110-D(Expiration Date:10/31/2014)
Section 3.HOPWA Outcomes on Access to Care and Support
la. Total Number of Households
Line [1]:For project sponsors/subrecipients that provided HOPWA housing subsidy assistance during the operating year
identify in the appropriate row the number of households that received HOPWA housing subsidy assistance(TBRA,
STRMU,Facility-Based,PHP and Master Leasing)and HOPWA funded case management services. Use Row c.to adjust
for duplication among the service categories and Row d.to provide an unduplicated household total.
Line [2]:For project sponsors/subrecipients that did NOT provide HOPWA housing subsidy assistance identify in the
appropriate row the number of households that received HOPWA funded case management services.
Note: These numbers will help you to determine which clients to report Access to Care and Support Outcomes for and will be
used by HUD as a basis for analyzing the percentage of households who demonstrated or maintained connections to care and
support as identified in Chart lb. below.
Total Number of Households
1. For Project Sponsors/Subrecipients that provided HOPWA Housing Subsidy Assistance: Identify the total number of households that
received the following HOPWA-funded services:
a. Housing Subsidy Assistance(duplicated)-TBRA,STRMU,PHP,Facility-Based Housing,and Master Leasing
b. Case Management
C. Adjustment for duplication(subtraction)
d. Total Households Served by Project Sponsors/Subrecipients with Housing Subsidy Assistance(Sum of Rows a.b.
minus Row c.)
2. For Project Sponsors/Subrecipients did NOT provide HOPIVA Housing Subsidy Assistance: Identify the total number of households that
received the following HOPWA-funded service:
a. HOPWA Case Management
b. Total Households Served by Project Sponsors/Subrecipients without Housing Subsidy Assistance
lb. Status of Households Accessing Care and Support
Column[1]: Of the households identified as receiving services from project sponsors/subrecipients that provided HOPWA
housing subsidy assistance as identified in Chart Ia.,Row 1 d. above,report the number of households that demonstrated
access or maintained connections to care and support within the program year.
Column[2]: Of the households identified as receiving services from project sponsors/subrecipients that did NOT provide
HOPWA housing subsidy assistance as reported in Chart Ia.,Row 2b.,report the number of households that demonstrated
improved access or maintained connections to care and support within the program year.
Note:For information on types and sources of income and medical insurance/assistance, refer to Charts below.
ill For project ill For project
sponsors/subrecipients that sponsors/subrecipients that
Categories of Services Accessed provided HOPWA housing subsidy did NOT provide HOPWA Outcome
assistance,identify the households housing subsidy assistance, Indicator
who demonstrated the following: identify the households who
demonstrated the following:
1.Has a housing plan for maintaining or establishing stable on- Support for
going housing Stable
Housing
2.Had contact with case manager/benefits counselor consistent
with the schedule specified in client's individual service plan Access to
(may include leveraged services such as Ryan White Medical Support
Case Management)
3.Had contact with a primary health care provider consistent Access to
with the schedule specified in client's individual service plan Health Care
4.Accessed and maintained medical insurance/assistance Access to
Health Care
5.Successfully accessed or maintained qualification for sources Sources of
of income Income
Previous editions are obsolete Page 16 form HUD-40110-D(Expiration Date:10/31/2014)
Chart lb.,Line 4: Sources of Medical Insurance and Assistance include,but are not limited to the following
Reference only)
• MEDICAID Health Insurance Program,or • Veterans Affairs Medical Services
use local program • AIDS Drug Assistance Program(ADAP) Ryan White-funded Medical or Dental
name • State Children's Health Insurance Program Assistance
• MEDICARE Health Insurance Program,or (SCHIP),or use local program name
use local program name
Chart lb.,Row 5: Sources of Income include,but are not limited to the following(Reference only)
• Earned Income • Child Support • General Assistance(GA),or use local
• Veteran's Pension • Social Security Disability Income(SSDI) program name
• Unemployment Insurance • Alimony or other Spousal Support • Private Disability Insurance
• Pension from Former Job • Veteran's Disability Payment • Temporary Assistance for Needy
• Supplemental Security Income(SSI) • Retirement Income from Social Security Families(TANF)
• Worker's Compensation • Other Income Sources
lc.Households that Obtained Employment
Column [1]: Of the households identified as receiving services from project sponsors/subrecipients that provided HOPWA
housing subsidy assistance as identified in Chart la.,Row ld. above,report on the number of households that include
persons who obtained an income-producing job during the operating year that resulted from HOPWA-funded Job training,
employment assistance,education or related case management/counseling services.
Column[2]: Of the households identified as receiving services from project sponsors/subrecipients that did NOT provide
HOPWA housing subsidy assistance as reported in Chart Ia.,Row 2b.,report on the number of households that include
persons who obtained an income-producing job during the operating year that resulted from HOPWA-funded Job training,
employment assistance,education or case management/counseling services.
Note: This includes jobs created by this project sponsor/subrecipients or obtained outside this agency.
Note: Do not include jobs that resulted from leveraged job training, employment assistance, education or case
management/counseling services.
[i For project sponsors/subrecipients that [2] For project sponsors/subrecipients that did
Categories of Services Accessed provided HOPWA housing subsidy NOT provide HOPWA housing subsidy assistance,
assistance,identify the households who identify the households who demonstrated the
demonstrated the following: following:
Total number of households that
obtained an income-producing job
End of PART 4
Previous editions are obsolete Page 17 form HUD-40110-D(Expiration Date:10/31/2014)
PART 5:Worksheet-Determining Housing Stability Outcomes(optional)
1.This chart is designed to assess program results based on the information reported in Part 4 and to help Grantees determine
overall program performance. Completion of this worksheet is o t_ i>al.
Permanent Stable Housing Temporary Housing Unstable Life Event
Housing Subsidy (#of households (2) Arrangements (9)
Assistance remaining in program (1+7+8)
plus 3+4+5+6)
Tenant-Based
Rental Assistance
(TBRA)
Permanent Facility-
based Housing
Assistance/Units
Transitional/Short-
Term Facility-based
Housing
Assistance/Units
Total Permanent
HOPWA Housing
Subsidy Assistance
Reduced Risk of Stable/Permanent Temporarily Stable,with Reduced Risk of Unstable Life Events
Homelessness: Housing Homelessness Arrangements
Short-Term
Assistance
Short-Term Rent,
Mortgage,and
Utility Assistance
(STRMU)
Total HOPWA
Housing Subsidy
Assistance
Background on HOPWA Housing Stability Codes
Stable Permanent Housing/Ongoing Participation
3 =Private Housing in the private rental or home ownership market(without known subsidy,including permanent placement
with families or other self-sufficient arrangements)with reasonable expectation that additional support is not needed.
4=Other HOPWA-funded housing subsidy assistance(not STRMU),e.g.TBRA or Facility-Based Assistance.
5=Other subsidized house or apartment(non-HOPWA sources,e.g., Section 8,HOME,public housing).
6=Institutional setting with greater support and continued residence expected(e.g.,residential or long-term care facility).
Temporary Housing
2=Temporary housing-moved in with family/friends or other short-term arrangement,such as Ryan White subsidy,transitional
housing for homeless,or temporary placement in institution(e.g.,hospital,psychiatric hospital or other psychiatric facility,
substance abuse treatment facility or detox center).
Unstable Arrangements
1 =Emergency shelter or no housing destination such as places not meant for habitation(e.g.,a vehicle,an abandoned building,
bus/train/subway station,or anywhere outside).
7=Jail/prison.
8=Disconnected or disappeared from project support,unknown destination or no assessments of housing needs were
undertaken.
Life Event
9=Death,i.e.,remained in housing until death.This characteristic is not factored into the housing stability equation.
Tenant-based Rental Assistance: Stable Housing is the sum of the number of households that(i)remain in the housing and(ii)
those that left the assistance as reported under: 3,4,5,and 6.Temporary Housing is the number of households that accessed
assistance, and left their current housing for a non-permanent housing arrangement,as reported under item:2. Unstable
Situations is the sum of numbers reported under items: 1,7,and 8.
Previous editions are obsolete Page 18 form HUD-40110-D(Expiration Date:10/31/2014)
Permanent Facility-Based Housing Assistance: Stable Housing is the sum of the number of households that(i)remain in the
housing and(ii)those that left the assistance as shown as items: 3,4, 5,and 6.Temporary Housing is the number of households
that accessed assistance,and left their current housing for a non-permanent housing arrangement,as reported under item 2.
Unstable Situations is the sum of numbers reported under items: 1,7,and 8.
Transitional/Short-Term Facility-Based Housing Assistance: Stable Housing is the sum of the number of households that(i)
continue in the residences(ii)those that left the assistance as shown as items: 3,4,5,and 6. Other Temporary Housing is the
number of households that accessed assistance,and left their current housing for a non-permanent housing arrangement, as
reported under item 2. Unstable Situations is the sum of numbers reported under items: 1,7,and 8.
Tenure Assessment. A baseline of households in transitional/short-term facilities for assessment purposes, indicate the number
of households whose tenure exceeded 24 months.
STRMU Assistance: Stable Housing is the sum of the number of households that accessed assistance for some portion of the
permitted 21-week period and there is reasonable expectation that additional support is not needed in order to maintain
permanent housing living situation(as this is a time-limited form of housing support)as reported under housing status: Maintain
Private Housing with subsidy; Other Private with Subsidy; Other HOPWA support;Other Housing Subsidy;and Institution.
Temporarily Stable,with Reduced Risk of Homelessness is the sum of the number of households that accessed assistance for
some portion of the permitted 21-week period or left their current housing arrangement for a transitional facility or other
temporary/non-permanent housing arrangement and there is reasonable expectation additional support will be needed to maintain
housing arrangements in the next year,as reported under housing status: Likely to maintain current housing arrangements,with
additional STRMU assistance;Transitional Facilities/Short-term; and Temporary/Non-Permanent Housing arrangements
Unstable Situation is the sum of number of households reported under housing status:Emergency Shelter;Jail/Prison;and
Disconnected.
End of PART 5
Previous editions are obsolete Page 19 form HUD-40110-D(Expiration Date:10/31/2014)
PART'6: Annual Certification of Continued Usage for HOPWA Facility-Based Stewardship Units(ONLY)
The Annual Certification of Usage for HOPWA Facility-Based Stewardship Units is to be used in place of Part 7B of the
CAPER if the facility was originally acquired,rehabilitated or constructed/developed in part with HOPWA funds but no
HOPWA funds were expended during the operating year. Scattered site units may be grouped together on one page.
Grantees that used HOPWA funding for new construction,acquisition,or substantial rehabilitation are required to
operate their facilities for HOPWA eligible individuals for at least ten(10)years. If non-substantial rehabilitation funds
were used they are required to operate for at least three(3)years. Stewardship begins once the facility is put into
operation.
Note:See definition of Stewardship Units.
1. General information
Operating Year for this report
HUD Grant Number(s) From(mm/ddlyj)To(mm/dd/yy) ❑Final Yr
❑Yr 1; ❑Yr 2; ❑Yr 3; ❑Yr 4; ❑Yr 5; ❑Yr 6;
❑Yr 7; ❑Yr 8; ❑Yr 9; ❑Yr 10;
Grantee Name Date Facility Began Operations(nm:/dd/yy)
2.Number of Units and Non-HOPWA Expenditures
Facility Name: Number of Stewardship Units Amount of Non-HOPWA Funds Expended in Support of the
Developed with HOPWA Stewardship Units during the Operating Year
funds
Total Stewardship Units
(subject to 3-or 10-year use periods)
3.Details of Project Site
Project Sites:Name of HOPWA-funded project
Site Information:Project Zip Code(s)
Site Information:Congressional District(s)
Is the address of the project site confidential? ❑ Yes,protect information;do not list
❑ Not confidential;01 ormation can be inade available to the public
If the site is not confidential:
Please provide the contact information,phone,
email address/location,if business address is
different from facility address
I certify that the facility that received assistance for acquisition,rehabilitation,or new construction from the Housing Opportunities
for Persons with AIDS Program has operated as a facility to assist HOPWA-eligible persons from the date shown above. I also
certify that the grant is still serving the planned number of HOPWA-eligible households at this facility through leveraged resources
and all other requirements of the grant agreement are being satisfied.
I hereby certify that all the information stated herein,as well as any in ormation provided in the accompaniment herewith,is true and accurate.
Name&Title of Authorized Official of the organization that continues Signature&Date(mm/dd/yy)
to operate the facility:
Name&Title of Contact at Grantee Agency Contact Phone(with area code)
(person who can ansit,er questions about the report and program)
End of PART 6
Previous editions are obsolete Page 20 form HUD-40110-D(Expiration Date:10/31/2014)
Part T: Summary Overview of Grant Activities
A.Information on Individuals,Beneficiaries,and Households Receiving HOPWA Housing Subsidy Assistance
(TBRA,STRMU,Facility-Based Units,Permanent Housing Placement and Master Leased Units ONLY)
Note:Reporting for this section should include ONLY those individuals, beneficiaries, or households that received and/or
resided in a household that received HOP WA Housing Subsidy Assistance as reported in Part 3, Chart 1, Row 7, Column b.
(e.g., do not include households that received HOP WA supportive services ONLY).
Section 1. HOPWA-Eligible Individuals who Received HOPWA Housing Subsidy Assistance
a. Total HOPWA Eligible Individuals Living with HIV/AIDS
In Chart a.,provide the total number of eligible(and unduplicated)low-income individuals living with HIV/AIDS who qualified
their household to receive HOPWA housing subsidy assistance during the operating year. This total should include only the
individual who qualified the household for HOPWA assistance,NOT all HIV positive individuals in the household.
Individuals Served with Housing Subsidy Assistance Total
Number of individuals with HIV/AIDS who qualified their household to receive HOPWA housing subsidy assistance.
Chart b.Prior Living Situation
In Chart b.,report the prior living situations for all Eligible Individuals reported in Chart a. In Row 1,report the total number of
individuals who continued to receive HOPWA housing subsidy assistance from the prior operating year into this operating year.
In Rows 2 through 17, indicate the prior living arrangements for all new HOPWA housing subsidy assistance recipients during
the operating year.
Data Check: The total number of eligible individuals served in Row 18 equals the total number of individuals served through
housing subsidy assistance reported in Chart a. above.
Total HOPWA
Category Eligible Individuals
Receiving Housing
Subsidy Assistance
1. 1 Continuing to receive HOPWA support from the prior operating year
New Individuals who received HOPWA Housing Subsidy Assistance support during Operating Year
2 Place not meant for human habitation
such as a vehicle,abandoned building,bus/train/subway station/airport,or outside
3. Emergency shelter(including hotel,motel,or campground paid for with emergency shelter voucher)
4. Transitional housing for homeless persons
5. Total number of new Eligible Individuals who received HOPWA Housing Subsidy Assistance with a Prior
Living Situation that meets HUD definition of homelessness Sum of Rows 2—4
6. Permanent housing for formerly homeless persons(such as Shelter Plus Care,SHP,or SRO Mod
Rehab
7. Psychiatric hospital or other psychiatric facility
8. Substance abuse treatment facility or detox center
9. Hospital(non-psychiatric facility)
10. Foster care home or foster care group home
11. Jail,prison or juvenile detention facility
12. Rented room,apartment,or house
13. House you own
14. Staying or living in someone else's(family and friends)room,apartment,or house
15. Hotel or motel paid for without emergency shelter voucher
16. Other
17. Don't Know or Refused
18. TOTAL Number of HOPWA Eligible Individuals(sum of Rows 1 and 5-17)
Previous editions are obsolete Page 21 form HUD-40110-D(Expiration Date:10/31/2014)
c. Homeless Individual Summary
In Chart c., indicate the number of eligible individuals reported in Chart b.,Row 5 as homeless who also are homeless Veterans
and/or meet the definition for Chronically Homeless(See Definition section of CAPER). The totals in Chart c. do not need to
equal the total in Chart b.,Row 5.
Number of Number of Chronically
Category Homeless Homeless
Veteran(s)
HOPWA eligible individuals served with
HOPWA Housing Subsidy Assistance
Section 2. Beneficiaries
In Chart a.,report the total number of HOPWA eligible individuals living with HIV/AIDS who received HOPWA housing
subsidy assistance(as reported in Part 7A, Section 1, Chart a.),and all associated members of their household who benefitted
from receiving HOPWA housing subsidy assistance(resided with HOPWA eligible individuals).
Note:See definition of HOP WA Eligible Individual
Note:See definition of Trans e� nder.
Note: See definition of Bene iciaries.
Data Check: The sum of each of the Charts b. &c. on the following two pages equals the total number of beneficiaries served
with HOP WA housing subsidy assistance as determined in Chart a., Row 4 below.
a.Total Number of Beneficiaries Served with HOPWA Housing Subsidy Assistance
Individuals and Families Served with HOPWA Housing Subsidy Assistance Total Number
1. Number of individuals with HIV/AIDS who qualified the household to receive HOPWA housing subsidy
assistance(equals the number of HOPWA Eligible Individuals reported in Part 7A,Section 1,Chart a.)
2. Number of ALL other persons diagnosed as HIV positive who reside with the HOPWA eligible individuals
identified in Row 1 and who benefitted from the HOPWA housing subsidy assistance
3. Number of ALL other persons NOT diagnosed as HIV positive who reside with the HOPWA eligible
individual identified in Row 1 and who benefited from the HOPWA housing subsidy
4. TOTAL number of ALL beneficiaries served with Housing Subsidy Assistance(Sum of Rows 1,2,&3)
Previous editions are obsolete Page 22 form HUD-40110-D(Expiration Date:10/31/2014)
b.Age and Gender
In Chart b.,indicate the Age and Gender of all beneficiaries as reported in Chart a. directly above. Report the Age and Gender of
all HOPWA Eligible Individuals(those reported in Chart a.,Row 1)using Rows 1-5 below and the Age and Gender of all other
beneficiaries(those reported in Chart a.,Rows 2 and 3)using Rows 6-10 below. The number of individuals reported in Row 11,
Column E.equals the total number of beneficiaries reported in Part 7, Section 2,Chart a.,Row 4.
HOPWA Eligible Individuals(Chart a,Row 1)
A. B. C. D. E.
TOTAL(Sum of
Male Female Transgender M to F Transgender F to M Columns A-D)
1. Under 18
2. 18 to 30 years
3. 31 to 50 years
51 years and
4. Older
Subtotal(Sum
5. of Rows 1-4
All Other Beneficiaries(Chart a,Rows 2 and 3)
A. B. C. D. E.
TOTAL(Sum of
Male Female Transgender M to F Transgender F to M Columns A-D
6. Under 18
7. 18 to 30 vears
8. 31 to 50 years
51 years and
9. Older
Subtotal(Sum
10. of Rows 6-9
Total Beneficiaries Chart a,Row 4
TOTAL(Sum
11. of Rows 5&10
Previous editions are obsolete Page 23 form HUD-40110-D(Expiration Date:10/31/2014)
c.Race and Ethnicity*
In Chart c., indicate the Race and Ethnicity of all beneficiaries receiving HOPWA Housing Subsidy Assistance as reported in
Section 2,Chart a.,Row 4. Report the race of all HOPWA eligible individuals in Column [A]. Report the ethnic i of all
HOPWA eligible individuals in column[B]. Report the race of all other individuals who benefitted from the HOPWA housing
subsidy assistance in column[C]. Report the ethnicjjy of all other individuals who benefitted from the HOPWA housing subsidy
assistance in column [D]. The summed total of columns [A] and[C] equals the total number of beneficiaries reported above in
Section 2,Chart a.,Row 4.
HOPWA Eligible Individuals All Other Beneficiaries
[A] Race [Cl Race
Category [all individuals [BI Ethnicity [total of [D]Ethnicity
reported in [Also identified as individuals [Also identified as
Section 2,Chart Hispanic or reported in Hispanic or
a.,Row 11 Latinol Section 2,Chart Latinol
a.,Rows 2&31
1. American Indian/Alaskan Native
2. Asian
3. Black/African American
4. Native Hawaiian/Other Pacific Islander
5. White
6. American Indian/Alaskan Native&White
7. Asian&White
8. Black/African American&White
9 American Indian/Alaskan Native&
Black/African American
10. Other Multi-Racial
11. Column Totals(Sum of Rows 1-10)
Data Check:Sian of Row 11 Column A and Row 11 Cohann C equals the total number HOPWA Beneficiaries reported in Part 3A,Section 2,
Chart a.,Roil,4.
*Reference(data requested consistent with Form HUD-27061 Race and Ethnic Data Reporting Form)
Section 3. Households
Household Area Median Income
Report the area median income(s)for all households served with HOPWA housing subsidy assistance.
Data Check: The total number of households served with HOPWA housing subsidy assistance should equal Part 3C, Row 7,
Column b and Part 7A, Section 1, Chart a. (Total HOPWA Eligible Individuals Served with HOPWA Housing Subsidy
Assistance).
Note: Refer to ho.-Il www.huduser.QMlportal/datasets/il/il2010/select Geogaphy mfr.odn for information on area median
income in your community.
Percentage of Area Median Income Households Served with HOPWA Housing Subsidy
Assistance
1. 0-30%of area median income(extremely low)
2. 31-50%of area median income(very low)
3. 51-80%of area median income(low)
4. Total(Sum of Rows 1-3)
Previous editions are obsolete Page 24 form HUD-40110-D(Expiration Date:10/31/2014)
Part 7: Summary Overview of Grant Activities
B. Facility-Based Housing Assistance
Complete one Part 7B for each facility developed or supported through HOPWA funds.
Do not complete this Section for programs originally developed with HOPWA funds but no longer supported with
HOPWA funds. If a facility was developed with HOPWA funds(subject to ten years of operation for acquisition,new
construction and substantial rehabilitation costs of stewardship units,or three years for non-substantial rehabilitation costs),but
HOPWA funds are no longer used to support the facility,the project sponsor or subrecipient should complete Part 6: Annual
Certification of Continued Usage for HOPWA Facility-Based Stewardship Units(ONLY).
Complete Charts 2a.,Project Site Information,and 2b.,Type of HOPWA Capital Development Project Units,for all
Development Projects,including facilities that were past development projects,but continued to receive HOPWA operating
dollars this reporting year.
1.Pro'ect S onsor/Subreci Tent Agency Name(Required)
2. Capital Development
2a.Project Site Information for HOPWA Capital Development of Projects(For Current or Past Capital
Development Projects that receive HOPWA Operating Costs this reporting year)
Note:If units are scattered-sites, report on them as a group and under type of Facility write "Scattered Sites."
HOPWA Name of Facility:
Type of Funds Non-HOPWA funds
Development Expended
this operating this operating Expended
(f applicable)
year year
(if applicable)
❑New construction $ $ Type of Facility [Check only one box.]
E]El Rehabilitation $ $ Permanent housing
❑ Short-term Shelter or Transitional housing
❑Acquisition $ $ ❑ Supportive services only facility
❑Operating 1 $ $
a. Purchase/lease of property: Date(mm/dd/yy):
b. Rehabilitation/Construction Dates: Date started: Date Completed:
C. Operation dates: Date residents began to occupy:
❑ Not yet occupied
d. Date supportive services began: Date started:
❑ Not yet providing services
C. Number of units in the facility: HOPWA-funded units= Total Units=
Fl f. Is a waiting list maintained for the facility? Yes El No
If yes,number of participants on the list at the end of operating year
g. What is the address of the facility(if different from business address)?
h. Is the address of the project site confidential? ❑ Yes,protect information;do not publish list
❑ No,can be made available to the public
Previous editions are obsolete Page 25 form HUD-40110-D(Expiration Date:10/31/2014)
2b. Number and Type of HOPWA Capital Development Project Units (For Current or Past Capital
Development Projects that receive HOPWA Operating Costs this Reporting Year)
For units entered above in 2a.please list the number of HOPWA units that fulfill the following criteria:
Number Designated Number
for the Chronically Designated to Number Energy- Number 504 Accessible
Homeless Assist the Star Compliant
Homeless
Rental units constructed
(new)and/or acquired
with or without rehab
Rental units rehabbed
Homeownership units
constructed(if approved)
3.Units Assisted in Types of Housing Facility/Units Leased by Project Sponsor or Subrecipient
Charts 3a.,3b.and 4 are required for each facility. In Charts 3a. and 3b.,indicate the type and number of housing units in the
facility,including master leased units,project-based or other scattered site units leased by the organization,categorized by the
number of bedrooms per unit.
Note: The number units may not equal the total number of households served.
Please complete separate charts for each housing facility assisted. Scattered site units may be grouped together.
3a. Check one only
❑ Permanent Supportive Housing Facility/Units
❑ Short-term Shelter or Transitional Supportive Housing Facility/Units
3b. Type of Facility
Complete the following Chart for all facilities leased,master leased,project-based,or operated with HOPWA funds during the
reporting year.
Name of Project Sponsor/Agency Operating the Facility/Leased Units:
Total Number of Units in use during the Operating Year
Type of housing facility operated by the Cate orized by the Number of Bedrooms per Units
project sponsor/subrecipient SRO/Studio/0 1 bdrm 2 bdrm 3 bdrm 4 bdrm 5+bdrm
bdrm
a. Single room occupancy dwelling
b. Community residence
C. Project-based rental assistance units or leased units
d.
Other housing facility
Suecify.
4.Households and Housing Expenditures
Enter the total number of households served and the amount of HOPWA funds expended by the project sponsor/subrecipient on
subsidies for housing involving the use of facilities,master leased units,project based or other scattered site units leased by the
organization.
Housing Assistance Category: Facility Based Housing Output: Number of Output: Total HOPWA Funds Expended during
Households Operating Year by Project S onsor/subreci lent
a Leasing Costs
b Operating Costs
C. Project-Based Rental Assistance(PBRA)or other leased units
d Other Activity(if approved in grant agreement)Specify:
e Adjustment to eliminate duplication(subtract)
TOTAL Facility-Based Housing Assistance
f. Sum Rows a.through d.minus Row e.
Previous editions are obsolete Page 26 form HUD-40110-D(Expiration Date:10/31/2014)
EXHIBIT "I"
MBE REPORTING FORM
HOPWA PSA CONTRACT 2015-2016--EXHIBIT"I"--MBE REPORTING FORM Page 1
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M&C Review
C t
d OUNCAL GENDA.
CONTINUED FROM A PREVIOUS WEEK
REFERENCE 17NS
DATE: 7/28/2015 NO.: G-18521 LOG NAME: HUDACTIONPLANPY2015-
2016
CODE: G TYPE: NON- PUBLIC YES
CONSENT HEARING:
SUBJECT: Conduct Two Public Hearings and Approve the City's 2015-2016 Action Plan for the
Use of Federal Grant Funds in the Amount of$9,820,979.00 from the United States
Department of Housing and Urban Development from the Community Development
Block Grant, HOME Investment Partnerships Program, Emergency Solutions Grant
and Housing Opportunities for Persons with AIDS Grant Programs, Authorize
Collection and Use of Program Income, Authorize Waiver of Application of Indirect
Cost Rates, Authorize Execution of Related Contracts and Adopt Appropriation
Ordinance (ALL COUNCIL DISTRICTS)
RECOMMENDATION:
It is recommended that the City Council:
1. Conduct two public hearings to allow citizen input and consideration of the City's 2015-2016
Action Plan for use of federal grant funds from the United States Department of Housing and
Urban Development in the amount of $9,820,979.00 from the Community Development Block
Grant, HOME Investment Partnerships Program, Emergency Solutions Grant and Housing
Opportunities for Persons with AIDS grant programs and for the use of program income from
activities using prior years' federal grant funds;
2. Approve the City's 2015-2016 Action Plan for submission to the United States Department of
Housing and Urban Development including allocations of grant funds to particular programs and
activities as detailed below;
3. Authorize the collection and use of an estimated $50,000.00 of program income, which resulted
from activities using prior years' Community Development Block Grant fund, for the reconstruction
of City streets;
4. Authorize the collection and use of an estimated $200,000.00 of program income, which
resulted from activities using prior years' HOME Investment Partnerships Program funds, for the
City's Homebuyer Assistance Program;
5. Authorize the City Manager or his designee to execute contracts for a one-year term with the
agencies listed in Tables 1, 2 and 3 below for Program Year 2015-2016 for Community
Development Block Grant, Emergency Solutions Grant and Housing Opportunities for Persons
with AIDS grant funds, contingent upon receipt of funding;
6., Authorize the City Manager or his designee to extend the contracts for up to one year if an
agency or department requests an extension and such extension is necessary for completion of
the program or to amend the contracts if necessary to achieve program goals provided any
amendment is within the scope of the program and in compliance with City policies and all
applicable laws and regulations governing the use of federal grant funds;
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7. Authorize a waiver of indirect cost rates as applicable for the Grants Fund in accordance with
the City's Administrative Regulations; and
8. Adopt the attached appropriation ordinance increasing the estimated receipts and
appropriations to the Grants Fund in the total amount of $9,820,979.00 consisting of
$6,332,270.00 in Community Development Block Grant funds, $1,934,447.00 in HOME Investment
Partnerships Program funds, $552,108.00 in Emergency Solutions Grant funds and $1,002,154.00
in Housing Opportunities for Persons with AIDS grant funds, plus any program income, all subject
to receipt of such funds.
DISCUSSION:
The City's 2015-2016 Action Plan summarizes the major housing and community development
activities and proposed expenditures for the program year beginning October 1, 2015 and ending
September 30, 2016 for use of federal grant funds totaling $9,820,979.00 from the United States
Department of Housing and Urban Development (HUD) for Community Development Block Grant
(CDBG), HOME Investment Partnerships Program (HOME), Emergency Solutions Grant (ESG)
and Housing Opportunities for People with AIDS (HOPWA) grant programs. It also summarizes
the use of program income resulting from activities using prior years' CDBG and HOME
funds. The purpose of these grant funds is to primarily benefit low and moderate income City
residents with ESG funds primarily benefiting homeless persons and HOPWA funds primarily
benefiting persons with HIV/AIDS.
Staff developed recommendations for the allocation of the estimated funding from HUD and
presented them to the Community Development Council (CDC) on May 20, 2015 and to the City
Council at its Pre-Council meeting on June 16, 2015. Notice of a 30-day public comment period
from July 1, 2015 to July 31, 2015 was published in the Fort Worth Star-Telegram on June 28,
2015. Any comments received will be maintained by the Neighborhood Services Department in
accordance with federal regulations. The City will hold two public hearings as part of the HUD-
required citizen participation process, the first on July 28, 2015 and the second on August 4, 2015
at which time the City Council is scheduled to approve the Action Plan. In addition, public
hearings were held on June 18, 2015 at 11:30 a.m. and 6:00 p.m. for citizens to provide comment
on the proposed list of neighborhood streets eligible for reconstruction using CDBG funds.
A summary of the CDC's funding recommendations is provided below in Tables 1, 2 and 3 and a
spreadsheet of all specific funding recommendations is attached. The 2015-2016 Action Plan
must be submitted to HUD by August 14, 2015.
CDBG
For Program Year 2015-2016, it is recommended that the amount of $6,332,270.00 in CDBG
funds and the estimated amount of$50,000.00 of CDBG program income be allocated as follows:
Public Services - $949,840.00
This item includes social services for low to moderate income, disabled and disadvantaged
populations.
Housing Programs and Services -$2,175,600.00
This item includes funding for the City's Priority Repair Program, Cowtown Brush-Up, homebuyer
and housing services, accessibility modifications to the homes of senior and/or disabled
individuals and related project delivery costs for these programs.
Infrastructure Services -$1,201,521.53
This item includes funding for the reconstruction of neighborhood streets.
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CDBG Economic Development -$738,854.47
This item is the City's annual payment on its Section 108 loan from HUD.
CDBG Estimated Program Income -$50,000.00
This item includes funding for the reconstruction of City streets in addition to the funds listed
above under Infrastructure Services. CDBG program income that is received which is over the
estimated amount but not used for reconstruction of City streets will be allocated to priority
activities in the City's Consolidated Plan subject to Council approval.
CDBG General Administration -$1,266,454.00
This item includes costs for administering the CDBG grant including allocations for Financial
Management Services, Internal Audit and Transportation and Public Works Departments.
HOME
For Program Year 2015-2016, it is recommended that the amount of $1,934,447.00 in HOME
funds and the estimated amount of $200,000.00 of HOME program income be allocated as
follows:
Homebuyer Assistance Program (HAP) - $1,097,400.00
This item includes funding for down payment and/or closing cost assistance to low and moderate
income homebuyers.
Community Development Housing Organizations (CHDO) Set Aside -$290,168.00
HUD requires that a minimum of 15 percent of HOME funds be allocated to CHDOs for affordable
housing projects and CHDO administrative operating costs. These funds will be used by Tarrant
County Housing Partnership, Inc. (TCHP), a CHDO, to construct additional single family houses
for the 21 lot Hardy Street Single Family Infill Development in the Diamond Hill-Jarvis
neighborhood (Council District 2). The houses will be sold to homebuyers making at or below 80
percent of area median income set by HUD.
Single-Family Development -$353,435.00
This item includes funding for construction by TCHP of additional single family houses for the
Hardy Street Single Family Infill Development.
HOME General Administration - $193,444.00
This item includes costs for administering the HOME grant.
HOME Estimated Program Income -$200,000.00
This item includes funding for the City's HAP for closing cost and/or down payment assistance in
addition to the funds listed above. HOME program income that is received which is over the
estimated amount but not used for HAP will be allocated to priority activities in the City's
Consolidated Plan subject to Council approval. HUD allows the City to take 10 percent of any
HOME program income to be used for the costs for administering the HOME grant.
HOPWA
For Program Year 2015-2016, it is recommended that the amount of $1,002,154.00 in HOPWA
funds be allocated as follows:
Non-Profit Service Providers $972,090.00
HOPWA Program Administration -$30,064.00
ESG
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For Program Year 2015-2016, it is recommended that the amount of$552,108.00 in ESG funds be
allocated as follows:
Non-Profit Service Providers -$510,700.00
ESG Program Administration - $41,408.00
CONTRACT RECOMMENDATIONS
The CDC and Staff recommend that contracts be executed with the listed agencies for the
amounts shown in the following tables:
Community Development Block Grant Contracts:
Table 1 - CDBG Agencies
Organization JPrograrn Amount
Cenikor Foundation Substance Abuse $ 75,000.00
Senior Citizen Services of Greater Tarrant Senior Services $ 75,000.00
County Inc.
YMCA of Metropolitan Fort Worth Child Care Services $ 75,000.00
YWCA of Fort Worth and Tarrant County [Child Care Services $ 49,840.00
Clayton Child Care Inc. d/b/a Clayton YES! Child Care Services $ 75,000.00
Girls Inc. of Tarrant County Youth Services $ 75,000.00
Camp Fire First Texas I Youth Services F$ 75,000.00
Lena Pope Home, Inc. Youth Services $ 75,000.00
The Ladder Alliance Employment/Job $ 75,000.00
Training
Tarrant County Housing Partnership, Inc. Housing Counseling $ 75,000.00
and Education
Case
Presbyterian Night Shelter Management/Main $ 75,000.00
Shelter
The Salvation Army, a Georgia Corporation Homeless Services $ 75,000.00
Meals on Wheels, Inc. of Tarrant County Home-delivered Meals Program Fs 75,000.00
CDBG Public Service Subtotal $ 949,840.00
Rehabilitation, Education and Advocacy for Project Ramp
F100,000.00
Persons with Handicaps, dba REACH, Inc.**
Total CDBG Contracts $1,049,840.00
**REACH will be funded from the CDBG Housing Programs and Services budget.
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Housing Opportunities For Persons With AIDS Contracts:
Table 2 - HOPWA Agencies
Organization Program Amount
Tarrant
County Administration (seven percent), Supportive Services, $420,063.00
Samaritan and Facility Based Housing Subsidy Assistance
Housing, Inc.
AIDS Administration (seven percent), Supportive Services,
Outreach Tenant Based Rental Assistance (TBRA), and Short $552,027.00
Center, Inc. Term Rent Mortgage and Utility Assistance (STRMU)
TOTAL
HOPWA $972,090.00
Contracts
Emergency Solutions Grant Contracts:
Table 3 - ESG Agencies
Organization Program Amount
SafeHaven of Tarrant County Shelter Services $104,265.00
Presbyterian Night Shelter Shelter Services F$ 85,908.00
Day Resource Center for the Homeless Shelter Services $141,092.00
The Salvation Army, a Georgia Homelessness $100,000.00
Corporation Prevention
YWCA Fort Worth and Tarrant County Rapid Re-Housing $ 79,435.00
TOTAL ESG Contracts F$M,700.00
These programs are available in ALL COUNCIL DISTRICTS.
FISCAL INFORMATION/CERTIFICATION:
The Financial Management Services Director certifies that upon approval of the above
recommendations, adoption of the attached appropriation ordinance and receipt of grant funds,
funds will be available in the current operating budget, as appropriated, of the Grants Fund.
TO Fund/Account/Centers FROM Fund/Account/Centers
21001 4310013 019CDBG $6,332,270.00
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21001 5XXXXXX 019CDBG $6,332.270.00
21001 4310013 019HOME $1,934,447.00
21001 5XXXXXX 019HOME $1,934.447.00
21001 4310013 019ESG $552.108.00
21001 5XXXXXX 019ESG $552.108.00
21001 4921001 019CDBG $50,000.00
21001 5XXXXXX 019CDBG $50.000.00
21001 4310013 019HOPWA $1.002.154.00
21001 5XXXXXX 019HOPWA $1002.154.00
21001 4921001 019HOME $200.000.00
21001 5XXXXXX 019HOME $200.000.00
Submitted for City Manager's Office by: Fernando Costa (6122)
Originating Department Head: Allison Gray (8030)
Additional Information Contact: Avis Chaisson (6342)
Leticia Rodriguez (7319)
ATTACHMENTS
17NS HUDACTION PLAN PY2015-2016 GR76 AO FY2015 docx
Action Plan 15 16 FINAL MandC Slides LHR.pdf
Proposed 2015 CDBG Infrastructure Project MandC.pd_f
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